Where are they pointing? A brief analysis of Medicare Advantage Star trends

This is the second installment of my deep-dive into Medicare Advantage Star ratings.? In my first article, I dove into how star ratings are constructed.? Here my goal is to give you a deep dive into these ratings over the last several years.

Executive Summary

• Overall weighted average for MA-PD plans has remained above 4.0 since 2019, with 43% of plans receiving at least a 4.0 in 2024.
• Receiving a 4.0 score is important for plans as it means an increase in bonus payments from CMS, but also a large marketing opportunity, as over 70% of enrollees choose at least a 4 star plan.?
• High performing regions emerge across the US, generally this is due to incumbent insurers (United, Cigna, Humana) who have greater experience in multiple geographic markets, along with health plans that have strong connections to health systems (Intermountain, UPMC).
• Raw quality measures have seen mixed performance results since 2019, meanwhile nearly all measures evaluating health plan customer service and patient experience have seen notable decreases.

National Trends

As a reminder, every year CMS releases star ratings for Medicare Advantage plans, measures are assigned their own star rating and are rolled up into summary scores for Medicare Advantage (MA) and Prescription Drug Plans (PDPs). Plans that offer both of these, MA-PD plans, receive an overall star rating. Here we are interested in the overall ratings. (If you're interested in how star ratings work, I wrote about them here)

Over the last 6 years, the weighted average overall summary score has hovered around 4.1 stars, which makes the average plan eligible for bonus payments.? Within the overall data, there are two distinct trends worth noting.??

Figure 1. Weighted Average of Overall Summary Score For MA-PD Plans from 2019-2024

In 2022: Due to the COVID-19 pandemic in 2020 and its impacts on the healthcare industry, CMS implemented a handful of provisions to support plans vs harm them:

• Expanding the hold harmless rule to all plan that wouldn’t punish them for any significant declines in performance.
• Applying disaster provisions to all plans. Plans star ratings would be compared to previous year, if the new rating was lower, the prior rating would apply. For example, if in 2021 the plan was assigned 4 stars but in 2022 CMS calculated a 3-star performance, then the 2021 rating of 4-stars would apply into 2022.

(Reminder: data used to produce stars ratings are dated by 1+ years.? Example: 2022 leverages data collected in 2020 the year of COVID-19 pandemic).

In 2024: CMS implemented a new methodology, the Tukey Outlier Deletion method, to deal with significant outliers in data before star measures are calculated.? Since the majority of the outliers were skewed to the lower end of performance, removal of them makes the overall average increase, shifts the cut points for coveted 4 and 5 star rankings higher.

We see these two items take fruition when digging into the contract distribution where the percent (%) of 4, 4.5, and 5 star contracts is much more significant in 2022, and then in 2024 we see a vast increase in 3.0 and 3.5 star plans, and a decrease in 4, 4.5, and 5-star plans from 2022 to 2024.

Figure 2. Percent (%) of Contracts By Their Overall Star Rating: MA-PD Plans from 2019 to 2024

As a reminder plans achieving with a 4-star rating are eligible for bonus payments on-top of any bid differences they submitted for CMS.??

Further, consumers are more likely to choose to enroll in 4+ star plans as noted in the following where we can readily see that over 70% of enrollees choose plans with 4 stars or greater.

(Author note: prior to posting this article, CMS released new reimbursement guidelines which can be found here.)

Figure 3. Net Enrollment for MA-PD Contracts?As A Percent (%) of Overall Star Rating in 2024

What role does geography play in plan scores?

If we look across the country, we can see a couple trends play out.? First, in 2024 the majority of all counties have access to a plan that is at least 4 stars or greater which is a large increase from 2019 where the majority of the central US was lacking access to a 4-star plan or even any plan available to them.

These are areas limited in both population and thereby minimal contract options.? For example, areas in Kansas and Nebraska may only have 2 or 4 plan options, while areas in Florida and Pennsylvania may have upwards of 40-60+ plan options to enroll into.

?Figure 4. 2019 Weighted Overall Score for MA-PD Plans

Figure 5. 2024 Weighted Overall Score for MA-PD Plans

A key driver of these high performing clusters are larger, more established national plans which have footprints in multiple states, for example CVS and Human are established across all of Florida, Pennsylvania, Tennessee and Utah, and are in the top 5 plans by enrollment for each of these states.?

Additionally, we see areas with strong health systems appear in these plans.? Such as Utah with Intermountain Health and Pennsylvania with UPMC.??

Figure 6. Top 5 Plans by Enrollment in Each State for FL, PA, TN, and UT That Achieved at Least a 4 Star Rating

Quality Trends

Now that we see a high level view of the star ratings, let’s dig into the measure data.

On review of the quality data for both the Staying Health and Managing Chronic conditions domains we see a couple trends:

• The Staying Healthy domain measures showed a general decrease in raw scores, along with a net decrease in 4-star cut points meaning performance has dropped for these measures across the board.
• Managing Chronic Conditions has shown more favorable changes over the last 6 years. With 9 out of 12 metrics showing an increase in overall score.? Measures associated with care management and medication reconciliation showed the greatest improvements. While osteoporosis management and all-cause readmissions showed significant decreases.

This represents ongoing trends in decreasing care quality seen since the COVID pandemic, shared by CMS.

For plans wishing to stay competitive, this means understanding not just current performance in these areas, but also analyzing how well you're improving as as staying consistent in your raw score will likely result in a decreased star rating for a number of measures over time.

Figure 7. Quality Data - Changes in Scores from 2019 to 2024

Note: only metrics that were used in both 2024 and 2019 are displayed above. Further notes can be found in the appendix

Patient Experience Trends

As a part of the stars evaluation, CMS reviews results from the CAHPS consumer survey sent to members, along with administrative data that looks at appeals process and reasons or disenrolling as a way to measure member and patient experience.

If healthcare quality was mixed, we see more negative trends in health plan experience and customer service.

Member experience showed significant decreases across the board, with access measures, ‘Getting Needed Care’ and ‘Getting Appointments and Care Quickly’ showing the most significant drops.?

Figure 8. Health Plan Customer Service

Figure 9. Member Experience with Plan

Figure 10. Member Complaints and Changes in Health Plan Performance.

While access to care has been challenging, especially since the COVID-19 pandemic, these negative results represents an ongoing trend in the Medicare Advantage space, with a couple key highlights:

1. In traditional Medicare, patients can get care anywhere that accepts Medicare, meanwhile entering into Medicare Advantage plans, members typically enter into a PPO or HMO plan that limits the organizations they can get care from. This has come under scrutiny in recent years as this is not always advertised when individuals enroll in plans.?
2. Further, Medicare Advantage plans have come under fire for excessive prior authorization requests making access challenging when it comes to access to both services and pharmaceuticals.

Finally, if we dig into the reasons for disenrolling, we can see some data from member sentiment take place where 'Problems with Coverage' and 'Problems Getting Plan to Provide and Pay for Care' are among the top reasons members choose to leave their plans.

Figure 11. Cited Reasons for Disenrolling - All Contracts

Summary

While Medicare advantage has become a lucrative opportunity for health plans, there remains much opportunity to support how it is operationalized.?

In future, it would behoove CMS to continue to make an emphasis on keeping adults healthy along with identifying opportunities to help individuals more readily gain access to care when it is needed.

Note: Data used in this article can also be found in both static and dynamic version on Tableau Public - https://public.tableau.com/views/MedicareAdvantageStarTrends/1_MAPDSummaryScoreTrend?:language=en-US&:sid=&:display_count=n&:origin=viz_share_link

Appendix:

Quality Measure Notes:

• New Measures in 2024: Follow-Up after ED Visit for People with Multiple High-Risk Chronic Conditions, Transitions of Care.
• Measures retired since 2019: Improving/Maintaining Mental Health, Improving/Maintaining Physical Health, Rheumatoid Arthritis Management, Adult BMI Assessment.
• Controlling High Blood Pressure was simplified from 2019 to 2024. 2019 allowed for members with a BP of 150/90 who were 60-85 with without diabetes to count toward the numerator. This was removed in 2024. (Measure also not in Star ratings 2020-2022)
• Plan All-Cause Readmissions calculation methodology changed from 2019 to 2024. 2024 expands to all members 18+. (Measure was also not in Star measures 2021-2023).

Weighted Averages - weighted average is used across this post when comparing plans to ensure contract size is taken into account when evaluating overall scores.? This helps ensure a more accurate representation by attributing a greater weight to large plans, and less weight to smaller plans which may skew averages one or or another.

Enrollment for each year was calculated using the last month of the prior year’s CPSC enrollment file from CMS.??

Example of how weighted average works below.? In a traditional average, all data points are weighted equally, this pulls the average score of ratings downward.? However, in a weighted average, we assign a weighting to the score, in this case enrollment, and sum all values to find the weighted average.

Weighted Average Example

Enrollment Files:

Enrollment and contract data were sourced from CMS’ Monthly Enrollment by Contract/Plan/State/County data here. ? Data was cleaned and joined using R. https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-advantagepart-d-contract-and-enrollment-data/monthly-enrollment-contract/plan/state/county

Measure and Star Data:?

Measure scores, overall ratings, and cut points were all sourced from CMS’ annual publication of the 2024 Star Ratings data tables found here.? Data was cleaned and aggregated using R. https://www.cms.gov/medicare/health-drug-plans/part-c-d-performance-data