Great Medication Management Goes Beyond the CMS Mandate

If pharmacy quality and Star Ratings performance are part of your role, you’ve likely spent this year rebuilding around measures that just changed, again. And this won’t be the last time.

In rapid succession, the Centers for Medicare & Medicaid Services (CMS) cut 11 Star measures under the 2027 Final Rule, followed by the Clover Health ruling, which put another approximately 20 measures into question. The legal dispute is ongoing and has already prompted the agency to recalculate ratings industry-wide, with no clear resolution in sight. The government has appealed the ruling, and the case could further determine the immediate and long-term stability of the Star Ratings framework.

Organizations and vendors that built their programs around specific measures are now scrambling to retool. But the ones that stayed grounded in the clinical needs of members didn’t have to, because they were already focused on providing proactive support that leads to better health outcomes, regardless of how that work gets measured.

Health plan leaders have a choice: keep reacting and chasing single-year compliance wins or establish a durable model designed to hold up in the long term regardless of what regulators decide next.

Don’t Let the Scorecard Drive the Strategy

The rulemaking whiplash illustrates just how fragile a strategy becomes when it’s closely tied to whatever CMS happens to be measuring at a given point in time.

And there’s a deeper issue: treating the measure set as the definition of good care in the first place. CMS measures track quality; they don’t create it, and they were never meant to define the standard of care.

Great medication management is evergreen. It will always include:

• Identifying clinical risk before it becomes a larger problem.

• Staying connected to members as they move across settings.

• Using new technology to help clinicians work more efficiently and reach more members.

That commitment should remain steady even as measures are added, removed, or recalculated.

Increasingly, the adoption of AI and machine learning (ML) tools is what makes emerging risk identification possible at scale, surfacing patterns across a member population that no single team could catch on its own.

Looking ahead, the goal shouldn’t be to build a program that survives CMS’s next rule change. It should be to build one focused on actual member health and clinical value. That combination is what keeps programs relevant even as requirements evolve.

Start With What Members Need

By 2030, all members of the baby boom generation will have reached age 65, at which point one in five U.S. residents will be of retirement age. This “New Old” cohort is living on its own terms. Some stay at home. Some travel. Others live in facilities, and some move between facility and home as their needs change. That range of settings means health plans need to keep pace with how people actually live.

The five critical medication-related Star measures—Comprehensive Medication Review (CMR), Medication Adherence, Statin Use in Persons with Diabetes (SUPD), Concurrent Use of Opioids and Benzodiazepines (COB), and Polypharmacy–Anticholinergic (Poly-ACh)—cover the most common medication-related challenges health plans need to address. Most plans still manage these one measure at a time, through separate teams and separate tools.

The plans best positioned to improve medication safety, adherence, and appropriate use for this on-the-go population are the ones that take a holistic, coordinated approach to these five measures, rather than a fragmented one.

What an Outcomes-First Strategy Looks Like

Clarest Path brings together one platform and one team to support members throughout their care journey, with all five medication-related measures under one roof. For members with more complex medication needs, this also includes closed-loop fulfillment.

This model combines technology, clinical resources, and physical infrastructure to meet members where they are to create seamless continuity of care. With over 600 clinicians, 15 pharmacies across 38 states, and more than 1,200 facility-based care settings, Clarest Health can follow members as they move throughout the healthcare system.

Clarest Path uses a real-time AI/ML engine trained by pharmacist experts to spot patterns in clinical data and outcomes that indicate potential and existing risks to member health. Every member call is made by a pharmacist or nurse, equipped with AI prompts and 3,000 pharmacist- and clinician-curated recommendations to help guide the conversations and deliver personalized experiences to members.

This offers health plans a scalable way to deliver consistent support across a diverse range of member needs.

Build for Outcomes, the Measures Will Follow

Volatility in Star Ratings isn’t new, but the speed of this year’s measure changes have tested every plan’s approach. CMS rulemaking and legal challenges will continue to reshape the landscape, but payers don’t have to let that instability define how they work.

The question is not, “How do we respond to the next measure change?” It’s, “How do we make sure our medication management strategy keeps improving care year after year, whatever the next set of requirements may be?”

Star measure performance is the byproduct of doing this work well, not the target. Focus on members’ health and performance will follow, even as the measures change.

Learn More: Read more about Clarest Path.