AH056 - Medicare Star Ratings: Updates, How Judi® Helps, and More, with Angela Kalantarova, PharmD

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for listening to this episode of Astonishing Healthcare. I'm Justin Venneri, your host and Director of Communications at Capital Rx, and I've got Angela Kalantarova in the studio with me today. She's a Senior Clinical Programs Manager here, and we're going to be talking about Star Ratings and some related topics.  

Angela, thanks for coming on the show.

[00:46] Angela Kalantarova, PharmD: Great. Thank you for having me.

[00:47] Justin Venneri: So tell us a little bit about your background and your path to Capital Rx. I'd love to hear how you got into clinical programs for Medicare, like our Stars program as well.

[00:56] Angela Kalantarova, PharmD: Yeah, of course. So I basically did finish my pharmacy degree in 2018. I went to the University of California, San Francisco. And then after that I wanted to specialize in managed care. So, I did a residency for a year, and I got to work at a health plan that was focusing on the Medicare population as well as Medi-Cal. And that's where I kind of got some Stars exposure.  

After that, I was able to start working for a medical group. I actually got to work on Stars team and kind of develop a process for all of the Stars measures and how we're going to outreach members and have a team to conduct all these outreaches and interventions and think of new and just different ways of how to improve member Star ratings.  

And so that kind of led me to Capital Rx, because, first, I was really the one helping do the interventions and planning and how we would execute on all of them. And then I got this opportunity with Capital Rx, which is now building the whole Medicare Stars program through like a technology side -- so providing all the information a client would need to go ahead and do the outreaches themselves. So really on the other side of doing the interventions all the time.

[02:06] Justin Venneri: Okay. And we spoke to Jay Tran, PharmD, about Medicare Stars last year. That was episode five of the podcast, and we have a blog on that too. And I'll link this stuff in the show notes, of course. And then episode 35 with Bonnie Hui-Callahan mentioned the impact clinical programs can have on Star ratings as well.  

Related Content:

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Poster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use
• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD

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So I think there are some new measures and some updates for 2025. Angela, can you go over what those are and what people need to know about them?

[02:31] Angela Kalantarova, PharmD: Yeah, of course. So Star Ratings are changing every year, which is very interesting. Like they change something little, sometimes something major.

So for this new year, there were some major changes because there are two new Stars measures. So, one of them is the polypharmacy. This is for older adults using anticholinergic medications. And really the reason why this measure is important is because some of these anticholinergic medications can cause side effects in members who are older. It can affect the central nervous system, cause blurred vision, confusion, and you know, we want to be able to mitigate that. And so those measures nicely capture that so that the plan can know how well that they're doing.  

And there's also concurrent use of opioids and benzos -- benzodiazepines. So those are for members 18 years and older. And also with these medications, you can decrease your motor skills and [they’re] very dangerous as well if patients are taking them together.  

So again, these both of these measures are really looking at basically taking two medications at the same time that maybe shouldn't be taken together.  

So with this, lower scores are actually better. And basically that means that lower score will show that you have fewer members who are taking these medications. So what's interesting about these, and what's a little bit challenging, is usually the adherence measures and the measures we've kind of talked about previously, you can track and monitor to kind of help improve those scores. With these measures because we only kind of identify them once they've already had those overlap, it is a little more challenging to kind of identify those opportunities. So you kind of have to think about different ways of how you would identify them.  

And so for Capital Rx, we look at the members first fill and we try to see, okay, what are the potential members? So it's definitely a bigger pool of members, but at least we can kind of address those members early, early on before those members are what we call “failed the measure” because they've already filled those medications.

[04:21] Justin Venneri: I would assume if they have some sort of adverse event or negative outcome because they ended up on these medications for too long or at the same time, then that would be a problem too, right?

[04:32] Angela Kalantarova, PharmD: Exactly, yes. So we'd want to make sure we can address those early on. Exactly.

[04:36] Justin Venneri: Got it. And then are there any other updates to CMS's methodology worth sharing?

[04:42] Angela Kalantarova, PharmD: Yeah, so every year, like they produce new measures, but they kind of also, the year before will start sharing some potential updates for the following years.  

So what's interesting right now, recently, they published the advance notice. We'll get a final notice in about a few months, in March and April. But what they are proposing right now is removing the MTM measure, or the Medication Therapy Management measure. So that will be a huge change if this does go into effect for, I think, the following year, because a lot of plans rely on this. It really helps improve member outcomes just because they do get to have that call with a pharmacist to go over their medications every year and identify any type of discrepancies that might be found -- you know, provide that extra education. So it will be very interesting to see what CMS decides for that.  

And additionally, there is the initial opioid prescribing. So that's a measure they're thinking about for next year, too, which will look at members who are just starting on an opioid, and if the day supply is greater than seven days. Because typically we don't want members to take these long term, so if they are taking that, we want to see the rate and we want to be able to identify those members who are.

Luckily, because it is a CMS requirement to have an edit in place, we do already kind of have an opioid edit where it's a soft edit, so you can override it. And this should help with the measure. But it will be interesting to see if this does become a new measure for 2026.

[06:11] Justin Venneri: And there's been -- I mean, MTM, we've covered that as well on the show and in our content, and our programs around it. I mean, that really seems like an interesting one to pull back on.

[06:21] Angela Kalantarova, PharmD: Yeah, I think we'll get more guidance in the next few months when they do release the final notice and on their decision why.

[06:27] Justin Venneri: Okay. And then if someone comes to you and asks, “Angela, how can I improve, you know, my Star Ratings, you know, based on the changes CMS has put in place, based on the existing structure, how the ratings actually come to be based on all the different measures that you get scored on as a health plan,” what are some strategies or tactics as you think about the future or look and look out to 2026? What would you say?

[06:51] Angela Kalantarova, PharmD: Yeah, of course. I think some of the strategies are really to kind of start early on in the year. From my experience, a lot of plans kind of wait until they start seeing issues, but I do think it's always better to start as early as possible.  

So in the case of adherence, what we try to do is provide these first fill reports that identify members before they enter into these measures, because then it gives whoever's doing the outreach more time to affect the member's behavior, educate them.  

And then same with the new polypharmacy and COB measure is because the same thing -- if we're not looking at this early on, then it's just going to be too late to kind of salvage anything. So, not only does it help the member, but it also helps the score, right?  

Other things we do is just, like, looking at 90 days conversions. So, for example, switching a member from a 30-day to a 90-day supply, so that way for the adherence measures, which are the triple weighted ones that really will affect the Part D score, those can be more easily addressed.  

There's also options to extend to 100-day supply. So, the idea here is members will need fewer fills throughout the year if they get not a 90-day but a 100-day supply. So we are seeing that more prevalent now with some of the plan changes.  

And then some things you can also do is just looking at medication adherence. You know, we recommend that the plans will make these medications lower co-pays at preferred or retail pharmacies or mail pharmacies. And they can also lower any of the return to stock thresholds, too. So, if you can refill the medication earlier, that will also help.

[08:25] Justin Venneri: Got it. If I'm hearing you right, it seems like A, communication early on with the members is always helpful and then, B, anything that makes it easier to access or more affordable is going to help with the measures too.

[08:36] Angela Kalantarova, PharmD: Exactly.

[08:37] Justin Venneri: And then regarding what we offer, you've alluded to how we do things a couple times already. How does Judi® help? I'm curious about leveraging our enterprise health technology and our platform. And what does success look like? Is it as simple as, you know, higher ratings in specific areas or some other measurements?

[08:54] Angela Kalantarova, PharmD: Yeah, of course. So Judi definitely significantly helps. I think that's what really drew me to Capital Rx is because our technology really helps us monitor these star ratings a lot better and easier.  

So coming from my previous experience, to track these ratings and to track how well you're doing, we would get reports that were like a month delayed. So you're still playing catch up because you're looking at scores from a month before, sometimes even longer. Because we have all the claims in-house and our logic calculates all of this and has the methodologies for it, we can actually see the claims in real time and that way it translates into the scores that we're seeing in real time. You can identify the members that you want to outreach today.  

And that's a big differentiator that we see with Judi is because a lot of the troubles, when people want to work on this and improve, is they're looking at claims that were maybe pulled a week before. So if I'm spending time calling a member or creating a fax or following up with a doctor, I might have already been wasting my time because it either got complete or you find a reason why you shouldn't be calling them -- something like that. So, our technology has been a huge differentiator.

[09:58] Justin Venneri: And so when I spoke with Amy Stockton last year and we talked to other members of the clinical care team, do you work closely with them to outreach to members or, because it's Medicare members specifically, it's kind of like a different team, different process?

[10:12] Angela Kalantarova, PharmD: Just to clarify what we do for our services is we kind of offer the actual dashboard and we offer access to it. So through our base admin fee, clients will get access to the dashboard and they can see their star ratings. Then we have a self-service option where we provide reporting and that's where that real-time data and the claims come through. Like every member that you would want to identify and target, all of their adherence metrics and so forth will all be listed out to really help for the client to conduct the interventions themselves. So they will use our reporting and tools to do those.

We also provide a full-service option where we will help complete outreaches, and we do partner with a vendor to do that. But again, we use our logic to help target the members that we want for outreach.

[10:53] Justin Venneri: Okay. That all makes a ton of sense. And I think we're at the last question here. So, what would you say, Angela, is the most astonishing or interesting thing that you've seen related to our discussion here today – Medicare star ratings -- that you can share, of course?

[11:05] Angela Kalantarova, PharmD: Yeah. So what I think is interesting is just how we continue to kind of build our technology. We're focusing on pharmacy claims, as, you know, is biggest thing with Capital Rx. But now this integration with medical and Judi Health™, it will be very interesting to see what happens. Because right now we're focused on the Part D measures with stars. If clients go into electing Judi Health and so forth, there could be potential opportunities for going into the Part C space because we will have some of that medical data.  

So that's what I'm interested in, seeing how that will develop, if that even goes that way. You know, we don't know if we'll go there, but at least it gives that option. So it is very interesting to see how much more we can expand in Medicare if that becomes an option.  

[11:49] Justin Venneri: That would be pretty cool. Well, we'll have to see if that's on the roadmap too.  

Well, Angela, thank you so much for taking the time to chat with us today, and I hope you have a great rest of your day.

[11:57] Angela Kalantarova, PharmD: Thank you. You too.

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