Comprehensive Medication Review Completion Rates and Disparities After Medicare Star Rating Measure

This cross-sectional study analyzes changes and disparities in comprehensive medication review (CMR) completion rates before and after implementation of a 2016 Medicare Star Rating quality measure.


Introduction
Each year, millions of US Medicare beneficiaries nationwide are eligible for medication therapy management (MTM) services provided by Part D plans through the Medicare-mandated MTM program to optimize medication regimens and therapeutic outcomes. 1,2A core MTM service is the comprehensive medication review (CMR), in which a pharmacist or other qualified health care clinician initiates contact with a patient (often a telephone call, but it could also be face-to-face, or part of a telehealth visit), reviews all of the medications a patient is taking, identifies any medicationrelated problems, discusses with the patient, documents a written summary in the Medicare standardized format, 3 and follows up with the prescriber as needed. 4,5CMRs have been shown to reduce medication-related problems, and in some cases, can lead to reductions in hospitalization and all-cause mortality. 4,6,7nce the inception of Medicare Part D in 2006, Medicare has required that Part D plans offer a CMR annually to beneficiaries who meet eligibility criteria.Medicare sets minimum eligibility thresholds as (1) having at least 2 to 3 chronic conditions, (2) taking at least 2 to 8 prescription drugs, and (3) having have high annual Part D drug spending (at least $4935 in 2023). 8,9Each Part D plan then sets their own MTM eligibility criteria based on these thresholds to determine to whom they offer a CMR.3][14] Specifically, Black and Hispanic beneficiaries were found to be less likely to meet Medicare minimum thresholds for MTM eligibility criteria, [12][13][14] and low-income beneficiaries were less likely to be offered a CMR, as well as complete a CMR, if offered. 10,11Rs have been underutilized historically, with only 17% of eligible Medicare beneficiaries receiving CMRs in 2014. 1 To encourage utilization, Medicare added CMR completion as a Star Ratings measure starting in 2016, where CMR completion is defined as receipt of at least 1 CMR during the measurement year 15 and requires documentation (with a written summary in Medicare standardized format).Individual Star Ratings measures contribute to the final summary star rating for each Part D plan that is shown on the Medicare Plan Finder website when beneficiaries are choosing Part D plans, are tied to financial incentives, and can influence beneficiary choice in plan (eAppendix in Supplement 1).16 To our knowledge, no studies have examined nationwide CMR completion rates following the 2016 adoption of CMR completion as a Star Ratings quality measure, and whether disparities have changed.To address this gap, this study assesses changes in CMR completion rates after the adoption of the 2016 Star Rating quality measure, and whether disparities in CMR completion changed across racial, ethnic, or socioeconomic group. Beneficiaries were also excluded if they were enrolled in a plan that participated in the enhanced MTM model, which provided further flexibility in services and eligibility criteria and was being tested by Medicare between 2017 and 2021 in 5 regions by 6 plan sponsors.18 Similar to actual practice with the MTM program, beneficiaries could be represented in multiple years within the 2013 to 2020 study period if they were deemed eligible for MTM services in multiple years.

Study Population and Measures
In additional analyses, we identified a secondary cohort by simulating an objective MTM-eligible population based on Medicare minimum eligibility criteria (ie, Ն3 common conditions, Ն8 Part D drugs, and $4255 in Part D drug spending for the year based on the 2020 threshold; see the eMethods in Supplement 1). 19Plans changed their eligibility criteria over time, so this cohort allowed us to also report CMR completion rates using a consistent and objective denominator for the entire study period.
The primary outcome in both cohorts was CMR completion, defined as receipt of at least except for dementia and hearing loss, which were not available for the entire 2013 to 2020 time frame and were instead based on algorithms used in prior studies. 23,24

Characteristics of Beneficiaries Deemed MTM-Eligible by Part D Plans
The    Abbreviations: CMR, comprehensive medication review; LIS, low-income subsidy; MTM, medication therapy management; SMD, standardized mean difference.
a Other race and ethnicity was defined as any other race and ethnicity not otherwise specified.
likelihood of completing CMR included rural residence and use of a greater number of medications in the prior year.

CMR Completion Before and After 2016
From 2013 to 2020, the number of CMR recipients increased from 7379 to 18 376 (Figure 1A).While the number of beneficiaries deemed MTM-eligible by plans increased from 2013 to 2015, this number decreased from 90 847 in 2015 to 51 386 in 2020 (Figure 1A).As a result, among the population in 2020 (Figure 1B), representing an increase of 3.5 times across the entire study period.Among a simulated MTM-eligible population based on applying CMS minimum eligibility thresholds consistently across years (ie, no changes in the eligibility criteria from year to year such as was evident by plans), the unadjusted CMR completion rate increased as well, but to a lesser extent, from 4.4% to 8.1% from 2013 to 2015 and then to 12.6% in 2020 (Figure 1B), representing an increase of 2.9 times across the entire study period.The size of the simulated MTM-eligible population increased year over year from 2013 to 2020 (eTable 4 in Supplement 1).
In adjusted analyses (  2).However, Asian and Hispanic beneficiaries continued to have lower estimated year-to-year CMR completion rates compared with White beneficiaries both before and after 2016 (Figure 2 and eTable 6 in Supplement 1).
Compared with White beneficiaries, Black beneficiaries had a smaller 1-time jump at 2016 but a greater post-2016 slope (Table 2), and model-estimated probabilities did not differ between Black beneficiaries and White beneficiaries (Figure 2 and eTable 6 in Supplement 1).Similar results across race and ethnicity were seen in the simulated MTM-eligible cohort (eTable 5 in Supplement 1).
Model-estimated probabilities for CMR completion were still lower for dual-Medicaid enrollees and similar for LIS-only enrollees when compared with those with neither Medicaid nor LIS both before and after 2016 (Figure 3 and eTable 6 in Supplement 1).

Discussion
This observational study using interrupted time-series analysis found that following the adoption of CMR completion as a Star Rating measure in 2016, CMR completion increased from 10.2% in 2013 to 35.8% in 2020.However, this CMR completion increase was in part due to Part D plans dramatically decreasing the size of the population they deemed to be MTM-eligible.8][29] When we simulated a cohort using minimum eligibility thresholds, CMR completion increased to a lesser extent, from 4.4% in 2013 to 12.6% in 2020.This finding suggests that the adoption of CMR completion as a Star Rating measure created strong incentives for Part D plans to take actions that could impact the rates, which they appeared to act on by shrinking the denominator (eligible population) instead of focusing only on growing the numerator (number of CMRs provided).
Likely in part to address this shrinkage in the MTM-eligible population, Medicare proposed changes in December 2022 to their minimum thresholds for MTM eligibility criteria.These changes included lowering the Part D drug cost threshold from $4935 in 2023 to be commensurate with the average annual cost of 5 generic drugs ($1004 in 2020), lowering the minimum number of covered Part D drugs required from a range of 2 to 8 drugs to 2 to 5 drugs, and requiring that Medicare Part D plans target 10 specified core chronic diseases. 30The goal of these changes is "to promote  consistent, equitable, and expanded access" 30 to MTM.On April 5, 2024, CMS issued a final ruling on the proposed changes in MTM eligibility criteria that will take effect starting in 2025. 31The Part D drug cost threshold was lowered to $1623 (and is based on the average annual cost of eight generic drugs), and Part D plans must target all 10 core chronic diseases. 31The number of Part D drugs was not lowered, but may be lowered in the future.Given these changes, the estimated expansion in beneficiaries eligible for MTM is from approximately 3.6 million (7%) to 7.1 million (13%). 31spite increases, CMR completion rates remained relatively low from 2013 to 2020, suggesting room for improvement and the need for additional strategies to help increase uptake.
Even though the MTM program has been around since 2006, a key barrier to CMR completion is patient and clinician lack of awareness of the MTM program and the benefits of a CMR. 32,33Patientand clinician-centered materials that educate on the value of CMRs, introduce the pharmacist who will conduct the CMR, and clarify that the CMR is covered by the Part D plan (ie, of no charge to the patient) could help increase CMR completion rates.5][36] Another reported barrier is the lack of a relationship between the clinician and the MTM practitioner (who is typically a pharmacist) performing the CMR, because this MTM practitioner generally works for a community pharmacy, MTM vendor, or the Part D plan, and not directly in the clinician's clinic. 37To address this barrier, novel approaches are needed.Perhaps one idea would be to contract MTM services to pharmacists who already work within a clinic and have established relationships with clinicians.When this is not feasible, another approach includes grouping MTM-eligible beneficiaries with the same prescriber to be assigned to the same MTM practitioner, thus encouraging the development of relationships over time.Further research is needed to explore ways to overcome barriers at the level of the patient, MTM practitioner, clinician, health system, Part D plan, pharmacy, MTM vendor, and the Medicare program.
We also examined whether the Star Rating measure was associated with CMR completion rate disparities by race, ethnicity, and socioeconomic status, given that prior studies have found that Black and Hispanic beneficiaries are less likely to meet Medicare minimum thresholds for MTM eligibility criteria [12][13][14] and that among those offered a CMR, Black beneficiaries do not differ in their likelihood of CMR completion but other racial and ethnic minority groups are less likely to complete a CMR. 10 Consistent with this prior work, 10,[12][13][14] we found that Black beneficiaries did not differ in likelihood of completing a CMR compared with White beneficiaries, but that Asian and Hispanic beneficiaries were less likely to complete a CMR than White beneficiaries.Asian and Hispanic beneficiaries' completion rates did increase more than White beneficiaries over time, but overall remained lower, indicating that disparities were not eliminated and suggesting the need for additional strategies.Prior studies 10,11 have also found that low-income beneficiaries were less likely to be offered a CMR, as well as complete a CMR if offered.Aligned with these prior findings, we saw that dual-Medicaid enrollees were less likely to receive a CMR and that prior to the Star Rating measure in 2016, dual-Medicaid enrollees and LIS-only enrollees had slower CMR completion growth rates.However, after 2016, dual-Medicaid enrollees and LIS-only enrollees' CMR completion rates increased faster than that of non-low-income beneficiaries.Nonetheless, dual-Medicaid enrollees had lower CMR completion rates compared with non-low-income beneficiaries both before and after 2016, indicating that although this disparity was reduced, it was not completely resolved.Medicare's focus on health equity, such as through new health equity quality measures and requirements to provide materials in non-English languages, may help to further reduce these disparities. 30ile the present study focused on CMR completion rates, it is important to note that this type of quality measure is limited in that it is a process measure. 38New initiatives by measure development organizations are underway to develop the next generation of CMR-related quality measures, such as outcome measures that focus on what goal was achieved from the CMR. 39rthermore, CMR completion rate is only 1 of 13 to 18 Star Rating measures depending on the calendar year (as described in the eAppendix in Supplement 1), so is only 1 consideration for Part D plans.

Limitations and Strengths
There are several study limitations we must report.First, there was no comparator group because CMR completion was adopted as a Star Rating measure for all Medicare Part D plans.Additionally, there could be residual unobserved confounding due to the study being observational in design and there being unobserved factors, such as patient activation.Second, information on race and ethnicity was derived from Medicare data, which is more likely to be inaccurate as compared with selfreported data 40 ; however, information on race and ethnicity was not available from self-reported data (eg, beneficiary surveys) for the entire study population.Third, we excluded beneficiaries (<11 per eFigure 1 in Supplement 1) enrolled in plans involved in a Medicare model testing Enhanced MTM, so the results are only generalizable to CMRs provided through traditional MTM programs (which represent the vast majority).A key strength of this study is examination of the long-term 2013 to 2020 trends in CMR completion.

Conclusions
In conclusion, this observational study using interrupted time-series analysis found that the adoption of CMR completion rate as a Star Rating quality measure was associated with higher CMR completion rates, in part because Part D plans used stricter eligibility criteria to define eligible patients.
Disparities in CMR completion rates were reduced for Asian, Hispanic, and dual-Medicaid enrollees, but not eliminated.These findings suggest that quality measures can inform plan behavior and could be used to help address disparities.
This observational study using interrupted time-series analysis was approved by the institutional review board at Duke University Health System and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.A waiver of informed consent was approved by the Duke University Health System because this was secondary analysis that met the requirements of the Common Rule.The primary study cohort was derived from 2013 to 2020 JAMA Health Forum | Original Investigation CMR Completion Rates After Medicare Star Rating Measure JAMA Health Forum.2024;5(5):e240807.doi:10.1001/jamahealthforum.2024.0807(Reprinted) May 3, 2024 2/14 Downloaded from jamanetwork.comby guest on 05/05/2024 Medicare 5% administrative claims data linked to 100% Part D MTM data.Patients consisted of community-dwelling Medicare Part D beneficiaries aged 66 years and older who met MTM eligibility criteria (as defined by each Part D plan) for at least 1 year in the study period and were continuously enrolled in Medicare Parts A, B, and D in the year prior to eligibility (eFigure 1 in Supplement 1).
2016-2020), and a 1-time aRR representing the 1-time incremental difference seen from 2015 to 2016 corresponding to the immediate change in policy (ie, change in intercept at 2016).In addition to these time terms, adjusted analyses included the aforementioned patient characteristics and included the Charlson Comorbidity Index score instead of individual comorbidities.In sensitivity analyses, the Charlson Comorbidity Index score was replaced by individual comorbidities and the time term parameter estimates were found to be robust (ie, not substantially change; data not shown).To determine whether the Star Rating quality measure was associated with CMR completion differently across racial, ethnic, or socioeconomic groups, we ran 2 additional models that included interaction terms between all time terms and subgroup indicators (model 1, race and ethnicity; model 2, dual-Medicaid, LIS-alone, or neither).We compared the aRRs for the 2013 to 2015 slope, 2016 to 2020 slope, and change in intercept at 2016 between each subgroup and the reference group, and also compared the model-estimated probability that an individual in each subgroup completed CMR each year from 2013 to 2020 using tests of the asymptotic χ 2 distribution of the likelihood ratio statistic.Model-estimated probabilities were calculated at the means values of all adjustment covariates.A statistically significant difference was defined at an α level of .05 or a 2-sided P value < .05.All analyses were conducted in SAS version 9.4 (SAS Institute).Data analysis was conducted from September 2022 to February 2024.

Figure 1 .
Figure 1.Unadjusted Number of Eligible Part D Beneficiaries and Medication Therapy Management (MTM) Completion Rates, 2013-2020

Figure 2 .
Figure 2. Model-Based Probabilities of Medication Therapy Management (MTM) Comprehensive Medication Review (CMR) Completion by Racial or Ethnic Group

Figure 3 .
Figure 3. Model-based probabilities of Medication Therapy Management (MTM) Comprehensive Medication Review (CMR) Completion by Dual-Medicaid or Low-Income Subsidy (LIS) Group 1.0

Table 1 .
Characteristics of MTM-Eligible Beneficiaries and Completers vs Noncompleters of CMRs Before vs After 2016 Star Rating Measure

Table 2 .
Change in Medication Therapy Management Comprehensive Medication Review Completion Rates Before vs After 2016 Star Rating Measure (N = 561 950) -2016 slopes (aRR for neither, 1.23; 95% CI, 1.18-1.28;aRR for dual-Medicaid, 1.35; 95% CI, 1.21-1.50;P < .001;aRR for LIS only, 1.27; 95% CI, 1.05-1.54;P = .02)(Table b Test between subgroup and reference group for a given time term.cOther race and ethnicity was defined as any other race and ethnicity not otherwise specified.post 1. eAppendix.Additional Background on Star Rating Measures eFigure 1. Cohort Inclusion Diagram eMethods.Simulated Cohort Definition Based on Medicare's Minimum Eligibility Thresholds eTable 1.Additional Characteristics of MTM-Eligible Beneficiaries and Completers vs Noncompleters of CMRs Before vs After 2016 Star Rating Measure eTable 2. Characteristics of MTM-Eligible Beneficiaries and Users vs Nonusers of CMRs Before vs After 2016 Star Rating Quality Measure (Using the Simulated MTM-Eligible Cohort Based on Medicare's Minimum Eligibility Thresholds) eTable 3. Patient Characteristics Associated With MTM CMR Completion After Adjusting for Time Trends (n=561,950) eTable 4. Descriptive Trends of Cohort Simulated as Eligible for MTM Based on CMS Minimum Thresholds and Breakdown of Cohort Based on Inclusion Criteria eTable 5. Change in MTM CMR Completion Rates Before vs After 2016 Star Rating Measure Using the Simulated MTM-Eligible Cohort Based on Medicare's Minimum Eligibility Thresholds (n=663,315) eTable 6. Model-based Estimated Probability of MTM CMR Completion by Subgroup and Year