Lightly edited for clarity.

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[00:22] Justin Venneri: Hello and thank you for joining us for another episode of the Astonishing Healthcare Podcast. This is Justin Venneri, your host, and our guests today, Angela and Jay, are both pharmacists and they've both been on the show before. Those episodes turned out great, so no pressure here for either of you. Angela Kalantarova is a Senior Clinical Program Manager here at Judi Health, and Jay Tran is now Vice President of Clinical and Client Operations. So congrats, Jay, and thank you both for coming back on the show.

[00:47] Jay Tran, PharmD: Thank you. Thanks for having me.

[00:48] Angela Kalantarova, PharmD: Thank you for having us.

[00:49] Justin Venneri: So, quick background before we get into it. If you're a listener and you're guessing, with Angela and Jay on, this is going to be about government programs and Star Ratings. But we'll get into that in a second. Before we do, quick backgrounds. Jay, for anybody who hasn't heard you before or doesn't know you, spend a minute on your background and your new role here.

[01:06] Jay Tran, PharmD: Yeah, no. Thank you, Justin. Jay Tran, VP for Clinical Operations and Client Operations here at Judi Health. I came here around 2021, so it's been about six years, really focusing on building our government programs and then expanding my role to focus on some of our clinical programs. I've been in the healthcare industry approximately 20 years. My primary experience has been in the government space: Medicare, Medicaid, and exchange lines of business. So I've been really involved from a health plan, PBM, and state Medicaid agency perspective. Coming here really helped Judi Health grow in this space.

[01:37] Justin Venneri: Awesome. Angela, how about you?

[01:39] Angela Kalantarova, PharmD: Yeah, so I've been here for about four years at Judi Health, and I am a Clinical Programs Manager. I really got hired on to help with the adherence program for our Stars Medicare program and also to help with adherence on the commercial side. So now I've also been getting into MTM and our Medicare programs focus, and then just working on other clinical programs within the team to help support.

[02:00] Justin Venneri: Awesome. So regarding the topics, let's start off with what's new. What should clients know about Stars and how they're changing for 2027? Jay, you want to start off?

[02:09] Jay Tran, PharmD: Yeah, I'll kick us off. I think the biggest thing everyone should really focus on moving into 2027 is the Medication Therapy Management program, the MTM program. It has been on a display measure for the past two years. What that means, essentially, is that CMS has temporarily adjusted the methodology for that particular program. They changed primarily the eligibility requirement. Whenever CMS changes a measure, they're required to keep it on display for a minimum of two years. From there, then it moves into a Stars measure. So approximately two years ago, that's exactly what happened with MTM. They expanded the eligibility, and because of that change, they had to move that measure to a display for two years. Now we're at the second year, and moving into 2027, it would go back to a Stars measure.

So it's really important for clients and plan sponsors nowadays to start focusing on MTM if they haven't. What's really interesting about this particular measure for the past two years is that, because it's a display measure, we do see a spectrum of interest from our clients. Some of them decided not to prioritize resources toward MTM, since it's a display measure and has no meaningful impact to quality bonus payments in their Stars measures. So there's a subset of clients, many of them, that probably don't want to prioritize resources for that initiative. Then I have a small subset of clients who do still care about the MTM Stars measure, and they're continuing to invest in that. Their philosophy and belief is, "I know it's not a Stars measure and it won't count during these two years, but I feel like there's momentum, and we have our provider groups highly engaged, and we want to keep the momentum going and set them up for moving into 2027 when it actually becomes a Stars measure." Then they're already ready to go.

So, two totally different philosophies here. Those who truly cared about it and really wanted to continue investing in the display measure, we have those, and then the others are deprioritizing. When it comes back in 2027, you're going to see a re-uptake of interest from a lot of those clients. In 2027, everyone's going to care about this. So continuing to focus on MTM is really, really important.

Just a little context and background. On the eligibility changes, they did change the disease states that qualify for this particular program. They also lowered the cost threshold from over $5,300 to $1,200 a year. Then the last criterion is based on the number of drugs the member is using per month. So you have three components of the criteria that expanded the eligibility. There are going to be more members. I think, with more members eligible for this program and it being a Stars measure, that's what led to the difference in some of the strategies we're seeing. In our population, we expected three to four times more potential members across the industry would be eligible for this program. For our clientele, what we've noticed is a two-times increase in the number of eligible members from 2025 to 2026. So those are some interesting facts that we're tracking. Moving into 2027, definitely start focusing on MTM.

[04:56] Justin Venneri: And in that focus, that expanded eligibility criteria, you mentioned the specific conditions. Can you share some of those, just for reference? Is this expanding into other disease states?

[05:05] Jay Tran, PharmD: Yeah, yeah, of course. These disease states are considered core, that you have to consider as part of the MTM program. Some are Alzheimer's, bone disease, arthritis, and mental health, just to name a few. So now those are becoming core disease states. You're adding members who may be eligible based on diagnosis codes when these weren't previously considered. So we have more of those indications that are now present.

[05:26] Justin Venneri: Got it. And what else out there has been, or is in the process of being, updated for this year and next? Angela?

[05:32] Angela Kalantarova, PharmD: Yeah, so for this year they did also update the SUPD measure. They made a small update where they're now making a denominator exception. Previously, for this measure, you needed statin therapy if you were identified as having diabetes based on pharmacy claims. Now, if members are on a PCSK9 inhibitor or bempedoic acid, which have been shown to help lower LDL and help target members with diabetes who would need that help, because of those guideline updates, they're now counting to exclude those members so they don't also have to take a statin. This one is a tricky one to improve on, because it's hard to get members to take a medication if they don't want to take it. So if they're already on this one, it's going to help some clients who do have these members on these medications. It'll be interesting to see how the results play out this year.

[06:17] Justin Venneri: And SUPD is statin use in persons with diabetes, right? I know the acronym is SUPD.

[06:22] Jay Tran, PharmD: Yes, exactly.

[06:23] Justin Venneri: Any others you're tracking?

[06:24] Angela Kalantarova, PharmD: The other one we are tracking is Medicare Plan Finder. This one is a measure that really just looks at how well we are reporting numbers, as far as our accuracy for the drug cost. So what's submitted to CMS, and then how it's actually reported on the claim and the cost to the member. Traditionally, clients have been doing pretty well on this one, and their rates are pretty high. So not a big impact that we're expecting. But basically, what happened is there were a lot of measure removals for 2027, and this is one of the ones that we are focusing on here at Judi Health. So moving forward, this one will be removed from the Star Rating. This will be going away. That's another thing that clients won't have to worry about.

[07:03] Jay Tran, PharmD: Yeah. And I have one more thing to add, actually, looking ahead in terms of other measures. The Initial Opioid Prescribing for Long Duration measure, the acronym is IOP-LD, follows PQA. This is a very specific measure. This one was actually interesting. It was mentioned in the 2026 proposed rules that they were thinking about adopting this as a 2028 Star Rating, which means it would apply to the 2026 measurement year. They hinted at that. And what is this measure? This measure essentially says that if you're 18 years or older and you've never been on opioids, and you do happen to get an opioid prescription filled, is it greater than seven days? If it's greater than seven days, those claims are not good and work against the plan. The thinking behind that is if you're new to opioids, you don't know how your body will tolerate them. There are different recommendations out there, including from the CDC, that say if you're new to opioid therapy, you shouldn't need more than a seven-day supply, just to see how you respond to it before you get a longer day supply on hand.

It's for safety reasons, but another way to think of it is that it's also a way to address some of the opioid epidemic that we've seen over the past decade here in the United States. It'll be interesting to see in the coming months what will happen, if CMS will actually move forward. For those who follow Stars, it's always anyone's guess. We don't know what they're going to do. What we do know is that a lot of times during the final notice or final rules, you'll see some inkling of where they're going to land. We'll probably get a preview in the coming few months in terms of some of the proposed rules and advance notice that they may share, and we'll get a sense. Then, as we move closer to mid-year next year, we'll see if any of that solidifies.

I think this is a display measure, and for clients who are tracking it, they have visibility into this particular measure and how they're doing. Some of the initial comments about this measure are that it's duplicative. "Hey, we already have a lot of these edits in place where you're addressing opioid concerns. Why are we implementing another opioid measure here? Are existing opioid edits not effective? Why would you want to add more?" What I would say is that it may be somewhat duplicative if you're thinking in terms of some of those opioid edits tied to this specific measure. But because there are existing edits and an existing understanding of this concern, it will probably be an easy measure for clients to meet, because they already have a lot of programs in place to address this. So this would be an easy, short win, I think, for a lot of our clients and plan sponsors if this actually moves forward as an actual Stars measure.

[09:23] Justin Venneri: Sure. So I guess the next natural question I have is, what are we doing to prepare, or to help our health plan clients prepare, for these Star measure changes? That one, definitely the opioid one, sounds like an easy potential "win," the way you described it, Jay. But Angela, do you want to go first here, and maybe circle back with the updates you provided for SUPD and MPF?

[09:42] Angela Kalantarova, PharmD: Yes. So for SUPD, we've already implemented the changes with our product team, since this was an update for 2026. That way, our clients are not targeting members who are already in a therapy that will be counted; that has already been implemented. For Plan Finder, we'll just make the updates to make sure clients don't have to send us the Plan Finder data. We don't submit it to MPF, so we will not be tracking that.

Other updates: for MTM, since it's been on display for the last two years, what we really did in preparation was to work with our clients to meet their goals in 2025 and 2026. That way, they are prepared in 2027. So, good news: in 2025 we did meet all of our client goals, whether they were below or above thresholds in the past. So, like what Jay mentioned, we had some clients who were like, "Okay, we don't really want to focus on this measure. We're going to scale back and see how it goes." And other clients were like, "No, we still need to make sure we are doing well, because in 2027 we don't want to be surprised with the eligible members." So both cases worked out the way our clients wanted. I feel confident that in 2026 we'll do the same, and that will help prepare them for 2027.

[10:39] Justin Venneri: Got it. Jay, how about you?

[10:40] Jay Tran, PharmD: Yeah, I would add to that: just watch out for that particular display measure, because it's been called out as a Stars measure, with potential adoption into 2028. Pay more attention to that as we move into the new year. So 2027 could be the year where you prepare a little bit and anticipate that new measure becoming a Stars measure.

[10:56] Justin Venneri: And sticking with you, Jay: we've been processing Medicare and Medicaid claims since January 2022, and as our book grows, I assume clients are asking for help with different things. What might you be able to help them with relating to Star Ratings or otherwise?

[11:10] Jay Tran, PharmD: Yeah, Stars is an important element for our clients. As you know, there are 40-plus measures. Part D only accounts for about half a dozen out of that. But we do hold some of the very critical ones on the pharmacy side that are triple-weighted, and those are your adherence measures. Clients are looking to Judi Health for the ability to provide real-time dashboard reporting, as well as detailed reports for them to implement various strategies with health plans. Their clinical teams generally have multiple strategies in place, and what I like to tell a lot of our prospects or existing clients is that Judi is here to give you information and tools to leverage what you currently do, not to overtake it in any way, and really to avoid any duplicative effort or initiatives.

A lot of our clients that have a Star strategy have very specific communication strategies or vendors that they work with, and maybe they don't want us to work on similar members. They want us to target another high-priority group. I think the data we provide and share gives them that intel to do that level of work. And some of the numbers here are showing some really great ratings that I'm seeing across our book of business in terms of our Stars measures. Looking at just measurement year 2025, our diabetes adherence is projected to land around 89%, which is a predicted four-star rating. For hypertension adherence, it's landing around 90%, and statin adherence is landing around 89%. Both of those are predicted to be a three-star rating.

For SUPD, statin use in persons with diabetes, it's around 84%. That has always been a challenge. What we're noticing is that once members don't want to start it, for whatever reason, typically some adverse effect, they just don't want to take it, and it's hard to get them back on it. Some of those adverse effects to the drug really reinforce the behavior of not wanting to take those particular drugs.

The other two things we're tracking are the new Stars measures, like the COB, which is the concurrent use of opioids and benzodiazepines, and also PolACE, which is the anticholinergic measure. The concurrent use of opioids and benzodiazepines is exactly what that is. What that measure is tracking is how many of your membership are actually taking both the opioid and the benzodiazepine. Both of those drug classes, when used concurrently, are not good, in terms of amplifying some of the negative sedation and negative side effects from those drugs. So the lower the number, the better you are performing. The same concept and idea applies for PolACE, the anticholinergic measure. It's a bunch of these high-risk medications that, when used concurrently, have a lot of sedative effects that could be bad for a particular member. So the lower the number, the better. When you have a lot of these anticholinergic medications used concurrently, that's just not a good outcome, potentially, for that member, with some of the side effects.

What's interesting looking at these two new measures is that we don't have an actual Stars rating, because they're relatively new. But what we are tracking, based on the reports that are available, is that across our book of business, the concurrent use of opioids and benzodiazepines is landing around 12%, which is 2% lower than the national average based on the 2025 data we have. For PolACE, it's 5%, which is 4% lower than the national average.

[14:05] Justin Venneri: That's great to hear. And that's like 4% lower, like four percentage points? So like 400 basis points lower, not a tiny 4% lower...

[14:12] Jay Tran, PharmD: 4% is smaller. And as small as that number is, it's very significant in the grand scheme when you're working with Stars, when everything could come down to a decimal point in whether you make it to the next level or not.

[14:22] Justin Venneri: Definitely. And Angela, I'm excited to hear the update from you, because I know you have some data and some updates on the Medicare Stars program overall and how that's gone. Our level-two program, right?

[14:31] Angela Kalantarova, PharmD: Yes, that's correct. Exciting news I wanted to share for Medicare Star Services level two. We had a client pilot the program last year, in 2025. After reviewing the data, we wanted to see how well the program was performing. Within just five months, the focus was adherence interventions. As you know, that's the main driver for heart Stars. Adherence interventions like refill reminders, immunotherapy, and just counseling to make sure the member takes the medication on time and doesn't have any barriers to getting their medication, and then switching to either a 90-day or 100-day supply to get them on a long-term medication, because that could also help with adherence.

So what we saw, between the three measures for adherence, that's between diabetes, cholesterol, and statin, was an average of 4.3% improvement for all these measures. If you look at it on the member level, the average PDC improvement, which is the proportion of days covered that we look at to track how well that adherence rate is: 9% of members, on average, who received an intervention had an improvement in PDC. And for any members who were non-adherent before, meaning their PDC was actually below 80%, so they would not be considered adherent, about 11% actually became adherent. That was really exciting news to see in such a short time.

Ultimately, what this resulted in is adherence improvement by measure. So in diabetes, we saw a 6% increase, statin a 4% increase, and a 3% increase in the star rate for hypertension.

[15:56] Justin Venneri: That's good stuff, right? And just in general, big picture: the Star Ratings mean that once they improve and rate better than average for the state, that equals payments, like bonus payments, for better outcomes, back to the plan. Right? That's the whole point of it.

[16:08] Angela Kalantarova, PharmD: Yes, exactly. The higher the Star Ratings, the more money they get to help perform better Medicare services for the members. More members are going to want to enroll because they are a five- or four-star plan. So that is definitely the goal for all these clients.

[16:19] Justin Venneri: I've got two more quick questions for each of you. I know you're busy, so I'll let you get back to your day job. Thank you for taking the time. Jay, if you want to take this first: I always like to ask how things work on the government program side of the business versus on the commercial side. What learnings are we sharing? How are we applying what we learn on one side of the business to the other? Where do you think there are opportunities, and why should the information matter to a plan sponsor more broadly?

[16:42] Jay Tran, PharmD: Yeah, no, great question. I think, at the end of the day, what are a lot of these quality measures focusing on and trying to accomplish? I think if members are educated and adherent, they'll have better outcomes. On the commercial side, we run different types of programs. On Medicare, it's different as well. The focus is different, too, between the two. On Medicare, you'll have mainly the Stars items, but on commercial, you're going to have a lot of clients and plan sponsors focusing on adherence, but for other drugs too, because they're sometimes held to URAC and PQA metrics, and they may focus on beta blockers for compliance or asthma medication. There's a whole different set of other measures that aren't being checked on Medicare Stars.

I think every member engages very differently, and how we deploy intervention strategies is very different between the two segments. With the Medicare population, we feel that deploying a particular intervention strategy works best, whereas your commercial population is a little bit younger and maybe more tech-savvy. I think we have different ways we would communicate and engage that particular membership. If you engage the member and they actually engage back with some of your interventions, there's a positive interaction that may lead to positive medication adherence. So, broadly thinking of the different types of populations and how it's deployed, it's very interesting to see how the two lines of business operate. We all strive for one singular goal of increasing medication adherence.

[18:05] Angela Kalantarova, PharmD: Oh yeah, and just to add to what Jay said. Exactly, we do adherence, and that's important for commercial or for Medicare. But also for commercial, even if they're not tied to any URAC or PQA measure, or any other NCQA/HEDIS body, plans really want to improve this, because it's overall going to help not just their measures, but the overall healthcare costs. One of the ways to prevent hospitalizations and prevent members from seeing the doctor when they don't need to is really helping them stay adherent and compliant to their medication, doing their checkups, and all that stuff, which is all included in these measures. So we tailor the strategies based on the line of business, but it's what we always want to strive for with a lot of our plans.

[18:43] Justin Venneri: All right, makes sense. Time for the last question, the most astonishing thing. As always, please keep your compliance hats on for this, but I'd love to hear a good story about something that surprised you over the last year or two. I mean, Jay, you were on for Episode 5. That's crazy. That's a while ago. I'd love to hear from you on something that surprised you over the last year related to government programs, Stars updates, and our discussion today.

[19:04] Jay Tran, PharmD: Yeah, I think the thing that comes to mind is that everyone is trying to increase medication adherence and increase their performance in these measures. You can deploy many different types of strategies to engage the member and have them take the medication. How do we get a paid claim in the system to count toward the adherence numbers? You can deploy many, many types of strategies. If you look at everything, it can be overwhelming. Something that people underappreciate or overlook is just some very simple things you can do. You can already address some of those numbers. It seems to always come down to a few things that you can just focus on and do. You could probably achieve some potential outcomes even if the plan just focuses on, let's say, refill reminders, or even extended-day-supply fills on a lot of these particular medications, or even lowering their refill-too-soon thresholds to allow early refills for these particular drugs. Those simple changes are sometimes even significant enough to actually impact your measures, without having to deploy all these various strategies, if you don't feel like they're effective, or maybe it's too much, or maybe it's cost-prohibitive due to budget reasons. But some very key things could help you improve some of these measures.

[20:11] Justin Venneri: And just a quick point. It's interesting you said refill-too-soon. You're adjusting that in a way that's helpful to the plan and the member. And I know we're very careful of that on the commercial side of the business, because people end up with excess supply. Does technology help control or limit that for the health plans, just like it does for the commercial members?

[20:27] Jay Tran, PharmD: Yeah, it's really, really important. It's interesting with Stars, because the philosophy is different. When a member decides to stockpile a drug, meaning fill a lot and have a lot on hand, for Stars it actually works in your favor. That overabundance of drugs, that overlapping day supply, as they call it, that extra supply actually counts into the future dates for you. So the more a member stockpiles, it actually helps the plan in terms of the Stars adherence numbers. But then you have to counterbalance that, because if everyone's stockpiling and has a lot of excess drug on hand, well, then that's a lot of unused drugs. And that leads to wasting plan-spend money on drugs when you don't need them. So there are two different dichotomies with that.

With our technology, what's really nice is what we can do in the system. For a non-Stars drug, we can do the traditional refill-too-soon, really make sure people use everything they have before getting their refill. But for the Stars drugs, we can relax that a little bit. And it's all done systematically and very easily in our system, where we can define what is a Stars drug and what is a non-Stars drug, and configure that very easily. Then, for clients who, for whatever reason, say, "I know that's not a Stars measure, but this is another measure that's important to me. Could we carve that out or add that in and do some additional customization to support that?" We can certainly support that as well. I think a lot of the technology we have with Judi allows us to quickly support those customer requests and configure them into the system.

[21:49] Justin Venneri: Angela, how about you? What's the most astonishing thing you've seen that's safe to share?

[21:53] Angela Kalantarova, PharmD: Of course. Yeah. So, going back to the program results I talked about, I think what I wanted to mention is that we made these Stars changes in such a short time. We would have been happy with a 1% increase in a lot of these measures, because it is really hard to move the needle. But, kind of what Jay was mentioning, staying consistent with these interventions and keeping track of these members is what really made the difference. Whether it's the extra outreach or the extra call, that really does help the members. So, to show the clients that this is possible, I think that's the key here. If we keep a program, or we decide to just do this or that, then if we stay on top of it and we work hard to do it, we can make some meaningful change. I think that's what's really awesome, and we luckily, at Judi Health, have the data and analytics to do that.

[22:33] Justin Venneri: Well, Jay and Angela, thank you both for taking the time today. I really appreciate you sharing your insights and some of these updates on the Stars program, Stars measures, and I look forward to staying in touch and seeing how these programs evolve.

[22:42] Jay Tran, PharmD: Thank you.

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