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Over the past two years, health plans that were once secure in their Star Ratings are finding themselves on shaky ground. Doomsday-like predictions of the Star Ratings landscape are common headlines in healthcare news. Fortunately, health plans can address recent CMS changes.
Previously, CAHPS and Administrative measures accounted for almost 60% of a plan’s overall Star Ratings. Today, for Stars 2026, they account for only about 40%. However, CAHPS and Administrative measure efforts are not to be abandoned altogether; there needs to be a significant shift in prioritization on the part of health plans toward addressing care gaps and disparities. With quality bonus payments and profits on the line, Medicare Advantage plans must improve health outcomes with the hardest-to-reach members to stay operational.
While the cost of investing in these members may look expensive on paper, the cost of not changing course will be even higher. Health plans that don’t take the time to reevaluate their Star Ratings and quality improvement strategy stand to lose millions.
What is increasing in Star Ratings measure weight are primarily member-driven metrics. These metrics include ensuring members take their medications on time, attend their appointments, adhere to their daily care plans, and stay up-to-date on necessary screenings—the day-to-day behaviors that are often lacking in the most expensive cohort of members who don’t respond to traditional member engagement tools. As Behavioral Scientist Dr. Sarah Watters says, “You can have the best dentist in the world, but they can’t come into your house and brush your teeth every night.”
Here are five things you can do to succeed in the fight to maintain and grow Star Ratings.
The Health Equity Index (HEI) will reward health plans that provide the highest quality of care to their most vulnerable member populations. These include dual-eligible populations, those eligible for Part D Low-Income Subsidies, and individuals on Medicare due to a disability. These are populations that are known to be at a greater risk of non-adherence and multiple chronic conditions.
CMS will measure and reward health plans on their ability to reduce healthcare disparities within these social risk factor (SRF) populations. This means ensuring you have a strategy to actively engage the unengaged and most vulnerable populations in your membership.
The HEI could make the difference of almost half a star in your future star ratings. Once the HEI goes into effect and the Reward Factor is sunset, 75% of current 5-star plans are estimated to decrease to 4.5 stars. A loss like this could devastate former high-ranking health plans, especially those teetering around 4 stars.
By focusing additional efforts on bridging care gaps for your members with greater social risk factors, you will also see greater improvements in Part C and D measures while closing the disparities measured in the HEI.
There is a high demand for growth and innovation in medication adherence, and health plans ought to invest in programs focused on closing the gaps in member behavior. Like the earlier example of having your dentist come to your house and brush your teeth at night, there might seem to be little health plans can do to move the needle on these Part D measures, but evoking principles of behavior change can help you better understand and better address why members are not partaking in these behaviors. When you know why not, you can then operate to remove the barriers in their way.
As humans, we are hardwired to desire instant gratification. While we all know eating healthy and taking your medication is good for you in the long run, they don’t always make you feel better in the moment. For those experiencing social risk factors, covering their basic needs will come before focusing on their long-term health. But by making participating in one’s health a rewarding experience, you increase engagement and make a habit out of it. Eventually, bringing attention to the positive changes provided by medication adherence: increased energy, weight loss, greater glucose regulation, and more.
Ensuring prolonged medication adherence satisfies three areas of Star Ratings:
Improvement measures are another category that may sometimes feel too ambiguous for health plans to effectively address. These measures focus on year-over-year continuous improvement on all measures in the Star Ratings. CMS calculates your improvement performance for Part C and Part D and assigns it one of three categories:
Focused efforts around incrementally hitting significant improvement and avoiding significant decline can prove to be fruitful in the Star Ratings math world as these are 5x weight measures. The heaviest weighted measures in the Star Ratings. Movement to hit Significant Improvement is usually much less of an effort versus movement to the next cut point and should be a strategy that health plans deploy to maximize performance. Focus on the 3x weighted measures and their ability to reach Significant Improvement can really move the needle!
While the weighting is decreasing, CAHPSⓇ is still essential because member experience is closely tied to other significant measures. Measuring CAHPSⓇ is the only tangible way to measure a member’s access and coordination of care. Without equitable access to care, members could struggle to complete their refills and, therefore, miss doses of their medications, which has ripple effects on continuous enrollment as well as their overall health outcomes.
Prioritizing access to care will also make a massive difference in measures such as breast cancer and colorectal screening and ultimately affect your health plan’s HEI standing. So, while the points for member experience may not seem as significant, it will be crucial for health plans to look at CAHPSⓇ and member experience to identify and address barriers to care.
While these are also decreasing in mathematical significance, health plans must still ensure that the measures under their direct influence are buttoned up. Appeals, Call Center audits, complaints and disenrollment need a heavy focus internally and cross functionally to assure you as a health plan are giving your members the best experience possible. These measures are rich sources of data that give you a direct look into what is not working and creating dissatisfaction and hurting member retention and loyalty. Leverage that to improve on these measures and tighten performance up since they are all worth 2x weight.
To learn more about the CMS Star Ratings changes and their implications directly from Star Ratings experts, watch this virtual session “Ask the Experts: Tackling CMS Changes for 2024, 2025, and Beyond” featuring Hayley Rogers, Consulting Actuary at Milliman, and Rex Wallace, CEO of Rex Wallace Consulting.
For more information on our dedicated Star Ratings solution, Wellth Northstar™ and a personalized Star Ratings assessment, reach the Wellth team here.
