As per a systemic review1 published in Annals of Internal Medicine, assessing the impact of interventions to improve adherence, it was found that about half the medications prescribed for chronic diseases are not consumed as directed by the physician, and around 20-30% of prescriptions are never fulfilled. This non-adherence results in over 125,000 deaths every year as well as increased emergency department visits and hospitalizations, which costs the American healthcare system to the tune of $100 to $300 billion1.
The focus of healthcare, globally, has been on treatment of disease and taking care of the sick. The approach has been reactive i.e. treat the sick. This approach basically leads to intervention only when the health of any person reaches a critical stage, with clinical intervention and hospitalization being the outcome. On top of this the healthcare system is constrained by spiraling cost driven by inefficient care system. This unsustainable economic impact of cost of care is driving the focus towards proactive health and care management.
Improving the quality of care and services to patients and enrollees is one of the key imperatives of Affordable Care Act (ACA). Several initiatives and measures have been put in place to make this imperative an operational reality across the entire healthcare landscape. CMS has posted quality ratings of Medicare Advantage plans (STAR Ratings) to help Medicare beneficiaries. All Medicare Advantage plans are rated on a one-to-five-star scale, with one star for poor performance, three for average, and five for excellent. Plan’s bonus payments are attached to STAR rating. CMS will have the authority to use its discretion to terminate the contracts of Part C and D sponsors that fail to achieve at-least a 3-star plan rating for 3 consecutive years beginning 2015. However, financial benefit and penalties represent only one dimension of the importance and relevance of the Medicare STAR ratings. It has also evolved into a key competitive advantage for the plans competing for Medicare beneficiaries. By design of Medicare STAR rating, any eligible Medicare beneficiaries can switch over to a 5 star rating plan any time during the year and not only during the open enrollment period. This is an immense advantage for performing plans!!