An Increased Risk for Drug Complications Creates an Increased Risk for Stars Measures

In 2025, Medicare Advantage plans encountered two new measures in the Part D Star Ratings Program related to medication use: Concurrent Use of Opioids and Benzodiazepines (COB) and Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (POLY-ACH). These medication safety measures provide an important signal to health plans, pharmacy teams and provider groups about what it will take to maintain high performance in the years to come. The change could place millions in quality bonus payments at risk for plans that rely heavily on traditional adherence and retrospective review models.

These measures are designed to address the growing population of seniors at risk for health complications due to concurrent or multiple drug use. The COB measure takes on the increased risk of visiting the emergency department, being admitted to the hospital for a drug-related emergency, and dying of drug overdose.¹ And, POLY-ACH the increased risk of dementia, cognitive disorders and other induced brain changes that come with use of anticholinergic medications². As inverse measures, each patient that hits the numerator criteria counts as a failure, and once a patient reaches that threshold, they remain in the numerator for the measure period unless they qualify for an exclusion, like hospice.

A member’s health status can change rapidly and for health plans tackling these measures at scale, real-time proactive monitoring, timely member outreach, and provider and pharmacy engagement are critical keys to success.  

Understanding these measures through the eyes of the member

For both measures, members enter a denominator first, meaning they have not yet failed the measure, but are at an increased risk for doing so. The denominator for these measures is built on two circumstances:

1. Two or more prescription fills for a qualifying medication (opioids, anticholinergic, benzodiazepines, etc.) on different service dates, and
2. Meeting cumulative days of supply thresholds or age requirements

The member fails the measure, and are counted in the numerator, if they meet the following criteria:

1. COB: 30 or more cumulative days of overlapping opioid and benzodiazepine use.
2. Poly-ACH: 30 or more cumulative days of overlapping use of two or more unique anticholinergic medications, with at least two fills of each.

These measures are particularly challenging as members are often long-term users of certain medications without fully understanding the cumulative effects of concurrent use. Or, an acute event, such as hospitalization, can cause them to fall out of compliance with the measures very quickly. Anticholinergic medications, many of which are available over the counter as antihistamines, sleep aids, motion sickness medications and cold medications are difficult to track through medical records or claims data as they do not generate formal prescriptions, or claims, for health plans to mine. A member who was recently hospitalized for a fall and prescribed opioids to manage pain may not properly report their regular use of depression or anxiety medication. Due to the abrupt nature of these changes, members may move into non-compliance simply with a single prescription fill.

Why traditional medication adherence programs don’t work

Traditional medication adherence programs offer a straightforward approach to medication management. There is no debate about the efficacy of the medication prescribed or the risks involved. The issue centers around member’s non-compliance with the doctor’s guidance. Traditional programs address this challenge by nurturing the member along a very linear path encouraging them to take their medications as prescribed.

These new measures bring an additional layer of complexity as they tackle drug interactions that could potentially have an impact on the member, that may also be prescribed by multiple providers. In a peer-reviewed study, as many as 51% of older patients were taking medications that were not recorded with their primary care physician.³  With providers sometimes unaware of the concurrent prescriptions, it removes them as a first line of defense, leaving the pharmacist or member on the front lines to challenge the doctor’s prescription. The pharmacist is put in a position to negotiate with the member to return to their doctor for guidance. And the member may feel that they are challenging the doctor’s guidance.

These new measures require knowing not only whether the member is taking the medication, but also if they are at risk for taking concurrent medications. Advanced logic must be built into any claims monitoring to accommodate these variables, while also considering the distinct role of the provider in these measures.

This environment poses critical challenges for compliance as the member must be informed, the care coordinated, and the systems in place to monitor the patient. Because health plans are often the only part of the larger system equipped to fill in all the knowledge gaps, they become the default integrator in a fragmented care system.

Engaging with Members: Decision Intelligence Designed for Poly-ACH and COB

Members that understand the effects of taking concurrent medications and are approached in a manner that is most meaningful to them are more likely to comply with the measure requirements. Talking through relevant substitutions, preparing them for and offering support to address withdrawal symptoms and reinforcing the need for ongoing communication with their provider can empower members to stay active in their medication management.

Key components of an effective member engagement strategy include:

1. Real-Time Decision Intelligence: Continuous evaluation of new claims that dynamically assign members to the correct clinical outreach stage accounting for those at risk for entering the denominator and those who are in the denominator but have not yet reached 30 days prevents numerator entry. It is also critical to create a strategy for “non-avoidable” members who will need step-down therapy and thus automatically enter the numerator.
2. Clinical Stage Calibration: Appropriate member segmentation in to “at risk,” “awareness,” and “highest risk” to deliver the right clinical and communication intervention at each stage reducing member abrasion and ensuring accurate messaging.
3. Medication Class Segmentation: Messages tailored to the exact medication class as effective outreach keeps in mind the differences between muscle relaxants and pain medication overlap vs antihistamine and antidepressant overlaps providing clarity and priority in communication.
4. Care Coordination Support: Messaging prompts that support overall care coordination and reduce risk, including encouragement to use one pharmacy, dispose of discontinued medication and to bring a full medication list to all doctor’s visits to support providers and reduce provider abrasion.
5. Event-Based Outreach: One-time urgent member outreach within the first 7 days of overlap to provide a three-week intervention window.
6. Real-Time Reporting: Continuous insights into which members have entered which clinical stage, the progression rates, prevented transitions into the numerator and overall overlapping day reductions inform adjustments and decisions.

Metrics That Matter

There are several key performance indicators that plans should track to best address these new measures:

Risk Identification:

1. The rate of new concurrent use within 30 days of post-discharge or a recent medical procedure or surgery.
2. Social Determinant of Health (SDoH) factors that could positively correlate to a high likelihood of reaching 30 days of overlap including access to mental health providers and opioid prescribing rate).

 Prescribing Behavior:

3. The percentage of concurrent use initiated by the same provider (move to provider section).

 Operational Exposure:

4. Members with mail order pharmacy as they are more likely to fill 90-day refills.
5. Strategies for members in avoidable vs. non-avoidable medication classes, stratifying the top medication classes responsible for the highest cumulative overlapping days.

One national plan running engagement programs related to these measures saw an immediate uplift in call center volume from members seeking guidance within weeks of starting their first member engagement campaign.

As CMS moves away from operational measures to focus on better care coordination, it will become increasingly difficult for plans to achieve higher Stars scores. The shift to triple-weighted COB and Poly-ACH measures illustrates that medication safety is no longer just about adherence, but navigating a complex environment of concurrent prescribing, fragmented care and rapidly shifting member risk. Plans that have strong alignment around resilient quality programs, operational efficiency, clinical excellence and best-in-class member experiences will be able to drive measures performance and do so in a way that keeps members happy, healthy and loyal for years to come.

MedOrion helps plan operationalize individualized engagement at scale bridging clinical measure logic and behavioral intelligence with AI-assisted member outreach to improve Stars ratings and improve member outcomes. To find out how MedOrion’s industry-leading technology platform can help your plan, request a demo today.

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