CMS wants a much tougher MA Star ratings program and that could challenge plans and mean billions in lost revenue.
NOTE: This blog is co-published with Lilac Software. See the end of the blog for more information on Lilac’s Stars platform and agentic AI solutions. If you are a Medicare Advantage plan or provider group looking to excel in MA Stars, my new venture is Lilac Software. Go to https://lilacsoftware.com to learn more about our Stars dashboarding, forecasting, best practice chase lists, and agentic AI solutions to drive Stars performance.
About The Podcast:
Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.
Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.
Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.
Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.
Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.
Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.
About The Episode:
On this episode, Marc discusses the fact that CMS wants a much tougher Star ratings program in Medicare Advantage and that could challenge plans and mean billions in lost revenue.
Key Takeaways:
Medicare Advantage Star ratings are in the doldrums. Little progress was seen in Star Year 2026 results.
Now, CMS says it wants to make the program even tougher. CMS is getting rid of “layup” measures — mostly operational metrics – in favor of concentrating on more complex clinical measures to drive quality outcomes.
This is not a total surprise as the Biden administration telegraphed this before leaving. The change would shift emphasis to drug, health outcome, and improvement measures.
CMS also wants to eliminate the Excellent Health Outcomes for All reward slated to go into effect for SY 2027 because it dislikes anything health equity.
The proposal to eliminate the long-planned reward could be legally dubious.
Getting tougher and refocusing is not unreasonable, but it could mean billions in revenue is lost by MA plans. At least 25% of contracts could lose at least half a Star rating.
Complicating the Stars picture is MA plans’ focus on dual eligibles and Special Needs Plans. These individuals tend to perform much worse on clinical measures.
To succeed, plans will need to invest more in Stars. The pivot to true healthcare outcome measures will require quicker and better data collection and analysis, better tracking and forecasting, ongoing strategy refinement, and novel tech-based interventions to close gaps on everyone.
Connect With Marc:
Resources:
The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
