Elevating Pharmacy’s Seat at the Table: Key Takeaways from the RISE Medicare Product and Pharmacy Strategy Summit

As the Centers for Medicare and Medicaid Services (CMS) guidelines evolve, clinical outcomes are carrying more weight, and pharmacy is no longer a back-office administrative function. It is becoming a frontline driver of Star Ratings and overall quality performance.

At the recent RISE Medicare Product and Pharmacy Strategy Summit in Seattle, clinical, quality, and product leaders gathered to discuss how plans can navigate these changes, move beyond outdated member outreach tactics, and build a credible path to higher Star Ratings. Jimmy WuRohe, CPO at Clarest Health, joined Jennifer Wirick, VP Pharmacy at Essence Healthcare, for a lively panel titled “Pharmacy Stars Strategy: Winning the Measures That Matter.” Here are some key takeaways and learnings from their discussion.

How Does Pharmacy Impact Medicare Star Ratings?

For years, medication measures and health plan quality metrics were managed in separate departments. Plan executives reviewed the results, but clinical pharmacy was rarely integrated into core business strategy.

That is changing. Recent CMS methodology updates have shifted how Star Ratings points are distributed, moving weight toward clinical performance:

• For the 2026 Star Ratings, CMS reduced the weight of patient experience, complaints, and access measures from 4 to 2. That change proportionally increases the influence of clinical and pharmacy measures on a plan’s overall rating. (CMS 2026 Star Ratings Fact Sheet)
• The three Part D medication adherence measures alone now carry a combined weight of roughly 11% of the 2026 Star Ratings, or 9 of 81 total weighted stars, making medication performance one of the most concentrated levers a plan has. (CMS 2026 Star Ratings Measures and Weights)
• The shift is expected to deepen. As CMS streamlines the measure set by removing lower-variation administrative measures, industry analysts estimate that clinical measures account for roughly half of the overall score today and could approach two-thirds under the proposed 2027 structure. Adherence measures are temporarily single-weighted during the transition to sociodemographic risk adjustment and are scheduled to return to triple-weighting in a later rating year, which will further concentrate clinical influence.

Because pharmacy is the most frequently used benefit in any health plan, pharmacists often have the highest volume of touchpoints with members. Executive teams are recognizing this, giving clinical and quality leaders a stronger voice in decisions that range from benefit design to community partnerships.

Retiring Archaic Tactics: Moving Past Mass Member Outreach

If a Star Ratings strategy still leans on uncoordinated, automated mass member outreach, it is time to retire that approach.

With CAHPS (Consumer Assessment of Healthcare Providers and Systems) scores carrying meaningful weight, bombarding a member with repeated, uncoordinated calls from different internal teams and vendors can do more harm than good. A plan might push a member to fill a prescription while lowering that member’s experience score in the process.

To stay competitive, plans are moving toward human-centric, personalized engagement:

1. Transitioning to Multimodal Communication

Seniors are more digitally active than ever. Plans benefit from moving past a phone-only strategy to capture and respect each member’s communication preferences, whether that is text, email, phone, or a digital application. If a member prefers text, routing them into an automated phone loop produces a broken experience and lower adherence.

2. Using Composite Assessments

When a care team secures an active touchpoint with a member, such as during a Comprehensive Medication Review under Medication Therapy Management, it is an opportunity to look at the member holistically. Addressing adherence, polypharmacy, and statin use in a single conversation is more effective than placing several disconnected calls.

3. Intelligent Risk Stratification and Personalization

Useful personalization is not about building the most complex predictive model. It is about using the data a plan already has to flag changes in behavior early. If a member who has been consistently adherent suddenly misses a mid-year fill, risk stratification can surface that anomaly quickly, allowing care teams to intervene before the member falls off track.

Strengthening Collaboration with Providers and Independent

A health plan’s pharmacy strategy cannot operate in a vacuum. Quality improvement depends on close alignment among the health plan, network providers, and local pharmacies.

Navigating the Provider-Pharmacy Workflow

Many provider groups and independent pharmacies are on the front lines of patient care and hold trust-based relationships with members. Plans can no longer expect providers to log in to separate portals to check quality data. Instead, plans need to integrate clinical recommendations and gaps-in-care information directly into the workflows providers already use.

When independent pharmacies and provider groups can see a patient’s full adherence picture, they are better positioned to support chronic disease state management and coordinate care. Sharing that data transparently helps the provider, the pharmacy, and the health plan align around the same goals.

Supporting Rural Health Communities

Rural health presents distinct access and adherence challenges. While mail-order programs are efficient on paper, many seniors in rural communities prefer their local independent or grocery-embedded pharmacies, which serve as important community resources. Plans can design flexible network strategies that support these local relationships. Where state scope-of-practice rules allow, collaborative practice agreements can empower rural pharmacists to act as an effective extension of the care team, taking on responsibilities such as chronic disease state management and, in some arrangements, limited clinical services.

Breaking Down the Silos for 2027 and Beyond

The goal for health plans is not simply chasing individual metrics to earn financial incentives. The larger opportunity is aligning pharmacy programs to improve a member’s overall cost and quality of care, including reducing hospital stays and preventing readmissions.

One perspective shared on the panel looked ahead to 2027: the possibility of moving away from treating Part C (medical) and Part D (pharmacy) as separate tracks. By integrating clinical data across both, respecting local provider and pharmacy workflows, and focusing on human-centric design, plans can build a more collaborative model where both the plan and the patient benefit.

Clarest partners with health plans to scale comprehensive medication management that improves adherence, supports Star Ratings performance, reduces readmissions, and lowers the total cost of care. Learn more here: For Payers | Clarest