CMS Pushes Organizations to Improve Star Ratings and Quality of Care

By Matt Phillion

Medicare Advantage plans often face a range of challenges in maintaining and improving their Star Ratings—everything from member churn to aging membership to increased competition. But moving from a 3.5-star to a 4-star rating can result in an average additional $400 per member per year.

To make that leap, though, organizations need to consider their approach—and their members themselves, says Jamie Jenkins, PhD, MBA, strategic advisor for government programs with Pager Health.

“I think the biggest struggle for health plans right now is they don’t know their populations,” says Jenkins. “There’s been a huge focus on health equity and social risk factors, and what CMS is doing is really forcing health plans to understand those populations and start reporting on those metrics.”

There are many barriers to getting care, Jenkins notes, from access, affordability, and coverage to social factors like transportation.

“It’s been a huge struggle for plans. You’d think they’d know basic demographics but they’re struggling,” says Jenkins.

Even reaching the patients can be an uphill battle, she notes, as patients change phone numbers, addresses, email preferences. Many times, plans may have only one phone number for an entire family, but they need to reach all adults in the family.

“Once you can engage with those members, you can bring forward a lot of value, but you’ve got to be able to reach them,” notes Jenkins.

This also means understanding how those patients want to be reached and interacted with.

“A black woman who is married, a mother, in her 50s, and a caregiver to an aging parent may have a different preference for interaction than a white single man without children or caregiving responsibilities,” says Jenkins. “Health plans need to get smarter about that. Different communities have different care needs and communication preferences. CMS is requiring quality measure level stratification based on race, ethnicity, and language.

The CDC has noted the growing number of people who speak languages other than English. In the U.S. in 1980, one in 10 people spoke a different language. As of 2019, we’ve seen that number triple to almost one in five, or 68 million people.

Knowing your members also requires geographical considerations. Healthcare is local. It’s about where you live, and what your local environment offers. Consider the impact on health due to fresh food deserts, violence in the home, and the lack of green space. These are big issues we must solve and all stakeholders (politicians, policy makers, community-based organizations as well as health plans and providers) have a role to play.

Members’ health situations change routinely, so engagement approaches also have to be regimented and personalized.

“For example, I moved from a larger city to a smaller town, and now my drive to a doctor is 30 minutes. It’s been a struggle to connect my kids with a pediatrician because they’re all booked up. A huge part of what determines our health is what you have access to and your ability to reach a doctor,” she says.

Expanding access

Jenkins points to the reemergence of other professional roles to help expand access where patients need it.

Take maternal care, for example, she says. A study by the Commonwealth Fund found that midwives could provide 80% of the necessary maternal care and could avert 41% of maternal deaths. This role could help address the workforce shortages we’re seeing for maternity care.

“There is more health plans can do to help solve the access issue,” says Jenkins.

Technological solutions including telehealth and digital approaches can bring providers where they are needed.

Actionable data continues to be a struggle.

“There’s so much data but being able to figure out what data you need, how to apply it, how to stratify it. Meanwhile, CMS is now requiring plans to report their quality performance against certain measures and to stratify that data.”

For example, when an organization reports its measures for breast cancer, they need to break it down by race and ethnicity and report that data so we can better understand the patient population.

“Black and [Native American] women are 40% more likely to die from breast cancer. Targeted campaigns are needed to reach these populations to close the existing disparities,” Jenkins says.

Following the money to success

When looking at Medicare Advantage, if an organization is not performing well in the Star System, they’re going to be losing money, says Jenkins.

“You have to have at least a three-star rating to make money in the program,” she says. And with higher ratings come more health plan benefits that can be passed along to members.”

“For example, when you have a lower star rating, members can leave at any time, but for higher performing organizations, there are designated periods when they can leave.  Frequent churn makes it difficult in many ways, including understanding the population you serve,” says Jenkins. “It’s chicken and the egg. You’ve got to make money and then you can offer supplemental benefits, which benefits both the plan and the members.”

And ratings help with attracting patients who are shopping around—just like any other industry, patients want the best-rated health plan and health facilities.

“[The ratings] help empower the public,” says Jenkins. Medicare members are becoming more tech savvy. They are using the internet to search for plans and providers based on those Star ratings. In 2023, 77% of Medicare beneficiaries used the Internet.

The intent is to deliver care at a lower cost as everyone is doing better all around, but to make this work, responsibility falls truly on everyone involved.

“The providers carry a lot of the load as the ones who have to deliver the service,” says Jenkins. “But patients have a responsibility to manage their care as well. And payers have to have benefits that align with its member populations. If you have a lot of diabetics in your population, for example, you are going to want to have diabetes management programs in place and accessible to the patients it needs to serve.”

And once again, this calls back to understanding your population: how do you serve a high-diabetic population in a food desert, or an area with no safe walking trails, or other missing resources to help patients get and stay healthy?

“Ultimately, research has shown that by not doing these things, the healthcare industry is costing itself billions of dollars. While the front-end cost of the investment is expensive, over time, it helps to improve health outcomes and cut down on costs,” says Jenkins.

“It’s in the best interest of the health plan to make it easy for their members to access nutritional food and help them find transportation to their doctor,” says Jenkins. “But this goes back to: if you have high stars and make good money, you can offer more benefits, but when star ratings get low, it can be tough to climb back up and invest in the services that bring value.”

It all comes back to the data, Jenkins says.

“When you look at the stars’ measures and the stratification of measures, it’s really about engaging with people, understanding the situation they’re in, where they are,” says Jenkins.

Knowing the population isn’t a one-time fix, she notes: it evolves over time.

“Make them part of the journey. It’s not a one-time thing. You can’t reach out to the patient once a year and expect that to create a relationship,” says Jenkins. “You want to know your provider and plan.”

Making this work requires understanding not just while the patient is in front of you but in all stages of their care journey. We’re beyond just the physical annual visits and have moved into a digital health care world where patient data can come from various sources including online questionnaires, digital surveys, mobile apps, wearables and connect medical devices. Using technology driven data, along with traditional data sources, could enrich our care approaches and bring the patient more fully into the care approach.

In some ways, Jenkins notes, the industry is on the right track: value-based care provides the right incentives for measure-level performance.

“We have to uncover and address health disparities, deliver holistic, personalized care using all available data sources,” she says. “I’m hopeful and excited to be part of the digital revolution that has the potential to engage members where they are and to move us closer to high quality outcomes for all members.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at