Right-Sizing Star Ratings: How Health Plans Can Adapt to a Changing Landscape
Key Takeaways
- Many Medicare Advantage plans continue to fall below 4 Stars due to rising cut points from Tukey outlier deletion, loss of hybrid data with digital-only measurement (eg, colorectal cancer screening), and uncertainty around the Centers for Medicare & Medicaid Services (CMS) rule changes, all of which require higher performance to maintain prior ratings.
- Success in raising Star Ratings requires long-term investment in whole-member care, holistic chronic disease strategies (eg, diabetes measures with combined weight of 13), social determinants of health (SDOH)-informed outreach, and early digital-data readiness to offset performance drops as more measures eliminate hybrid reporting.
- Member experience improvement is increasingly driven by year-round engagement, personalized multichannel communication, artificial intelligence (AI)-supported outreach, and growing adoption of digital tools, with regional plans demonstrating that agility, hyperlocal insight, and data-driven innovation can accelerate Star gains.
Please introduce yourself by stating your name, title, and any relevant clinical experience you’d like to share.
Marge Ciancetta: My name is Marge Ciancetta. I'm the product manager for Cotiviti Star Intelligence Solution. I really enjoy finding ways to turn data into knowledge and knowledge into action. I love what I do.
For the fourth year in a row, many Medicare Advantage plans fell short of the 4 Star mark. What underlying trends or persistent challenges do you think are contributing most to that continued difficulty?
Ciancetta: It is a great question and definitely a trend. It's not an anomaly that we're seeing Star Ratings reduce again this year. A couple of things came to mind for me; the first is that the average in the Star Rating program is 3 Stars, not 4.
During the COVID-19 pandemic, we had a lot of overinflation of Star Ratings, and we're seeing that dissipate now. I would call it more of a right-sizing than a reduction in overall Stars. That's important to keep in mind as you think through the data.
Beyond that, there have been quite a lot of changes to the Star Ratings program over the last few years, and I think it's important to call those out as well. The Tukey outlier deletion method has continued to draw Star Ratings cut points up. They're fully implemented at the 4- and 5-Star level, but the 2- and 3-Star cut points still have some increases that they'll undergo over the next couple of years.
The general theme there is that cut points continue to get harder, and plans can't just maintain the same performance and expect their Star Rating to stay the same. It's going to drop. They have to be working harder.
There's also the transition to digital measurement, which I think we're just starting to see the beginning of. Colorectal cancer screening is the first measure that eliminated hybrid and is now only reporting via digital. That measure saw a 5% decrease in all of its cut points across all 4 Star Rating levels this year, showing that the industry as a whole is struggling with that transition.
Essentially, they just don't have the digital data to replace the chart review that they were doing previously. I do expect that other measures that transition to digital measurement will have that same drop in performance. Plans have a long road ahead of them to completely make up for that difference elsewhere and get their rates back up to where they were before.
Lastly, there's a general feeling of uncertainty around the Star Ratings program. We had a new administration come in at the beginning of the year with a different agenda than the previous administration. They proposed a lot of changes but finalized none of them in the final rule. [Some plans don't know] where to invest and what their long-term strategy is going to need to be. There are a couple examples of that. The Centers of Medicare & Medicaid Services (CMS) proposed to remove all of the complaints, appeals, and teletypewriter (TTY) measures. Knowing that any of those could be retired affects your ability to invest in them.
To sum all of that up, the bar is getting higher each year. There are a lot of methodology changes through weight changes, new measures that are coming in, old measures that are being phased out, and it can be hard for plans to know where to focus on how to maintain or improve their Star Ratings.
How can plans balance the pressure to quickly raise Star Ratings with the need to invest in longer-term improvements, like member engagement or provider collaboration?
Ciancetta: Star success is definitely not a sprint; it's a marathon. It really has to be baked into a plan's DNA in terms of how they approach everything. They have to have the right building blocks in order to succeed on a regular basis in this program. It's one thing to chase hits at the end of the season during fourth-quarter push, but to do so consistently year-over-year requires a long-term strategy.
If I were a plan trying to figure out how to balance those things, I would recommend focusing on mastering the basics and building a strong, solid foundation. Some examples I have of that are to see how you can approach things holistically. Diabetes care management makes up a weight of 13 across the entire program between the medication adherence, eye exams, kidney exams, and the HbA1c.
If you think about your diabetic population as a whole and approach all of those measures as a whole, it's a great way to have a singular population in mind. To improve the rates, focus on improving the care across that continuum of measures by focusing on the same population.
Another example I had of this is focusing on whole-member care. I've worked at a health plan. I know that a lot of plans tend to work one measure at a time. You have your breast cancer screening list. You call everybody and tell them they need a breast cancer screening. But if you look at the bigger picture and see that this person had a hospitalization, they have a couple of chronic conditions, and some unmanaged conditions, it can change your approach.
If you add on social determinants of health (SDOH) factors, you get a much broader picture of what's going on with a specific member. Maybe they're noncompliant because they don't have the transportation or provider access they need. Helping them overcome those gaps can improve their scores and their compliance across the continuum of measures that they're in as well. Those themes are similar. How can you lump things together, look at the big picture, and find those themes where you're struggling to try to affect them holistically?
Digital data collection is another one that plans really have to prioritize now for that long-term effect. Heavily weighted measures have a much greater impact from hybrid data collection. When that goes away, plans are going to feel the effect if they aren't taking those long-term steps to improve their digital data today. It has to be a blend of long-term and short-term focus.
Member experience remains a heavily weighted factor in Star Ratings. What innovative or practical steps are plans taking to genuinely improve the member journey rather than just survey scores?
Ciancetta: There's a lot of innovation going on in this area. The measures dropped from a 4x weight to a 2x weight starting in Star Rating year 2026. A lot of plans invested heavily in those measures and lost some of that investment as they were reduced. However, a 2x weight is nothing to dismiss at an individual-measure level either.
They do still make up a significant component of the Star Ratings program. There are a lot of innovations that are going on there, and it can be a strategic pillar in your Star success to focus on these measures. I would say that the most successful organizations are treating this as an opportunity to invest in year-round engagement instead of just seasonal pushes. They're trying to contact their members on a regular basis, establish those relationships, and are not just calling when there's a problem.
There have also been a lot of opportunities to produce multichannel and personalized communication. I know that's something that we're working on at Cotiviti as well—to be able to ask, "How does each member prefer to be reached? How can we make it easier for them to become aware of the services, get scheduled for an appointment, and understand how to take better care of themselves?"
There is a lot of opportunity there to use artificial intelligence (AI)-personalization to reach out to each member en masse in the way that they prefer to be reached. It's a very exciting area right now and one where I think we'll still continue to see a lot of growth.
There's more opportunity than ever to close the gaps through digital tools. We're seeing more and more platforms. In general, the Medicare population is becoming not only more aware but also more accepting of those digital tools. It's no longer a new innovation. It's something that they can relate to and that they can understand how to use. They can go there to refill their prescriptions, send a message to their doctor, and download the member education materials. It's becoming more of a day-to-day part of their routines. It's much easier to work on those member experiences with those types of digital tools in place.
We’ve seen some regional Medicare Advantage plans make notable Star Rating gains in recent years. What lessons or best practices from those smaller, agile organizations might larger national plans be able to learn from?
Ciancetta: I love that question. There is what I call a sweet spot for plan age. Newer plans under 5 years old tend to struggle a lot because they're still working out their operational kinks and figuring out their best practices. For plans that are over 10 years old, it's like trying to turn a cruise ship. They have such extensive infrastructure, and it can be really hard to move the needle when you have so many established best practices and procedures.
For plans that are 5 to 10 years old, that really is the sweet spot. You're not too established that it becomes hard to change, you don't have too many legacy systems and processes in place, and you can really be innovative. These are the plans that do a really good job of measuring their returns on investment (ROIs).
You might have 5 different types of outreaches. Which one is bringing you the most bang for your buck? If it's not producing the way that you need it to, stop doing it and try something else. Innovation is what's going to really drive plans to rise to the top and get that 5 Star year after year. You have to be doing that kind of innovation. You have to be doing that type of data-driven analysis in order to make that happen.
One other thing I'll say is that those mid-range plans—not the big national plans—can have much more of a regional, hyperlocal focus that helps them have a much better idea of who their population is. They can do community centered events, and they can understand the SDOH components that are affecting that particular area and design their benefits in a way that supports that population well. They have a leg up compared to a national in those ways.
If I were a national plan, what I would probably be focusing on is a way to centrally gather data and do analysis, but then try to decentralize that governance of how each program is run across the nation so that each of your contracts can be tailored to its own regional needs. Let the people who live in those areas monitor those populations and be the experts on what those populations need.
The bottom line is that regional plans succeed because they combine that local insight with operational agility. National plans that decentralize decision-making, personalize member engagement, and strengthen provider collaboration can achieve similar gains without losing those benefits of scale.
