United States: 2025 Star Ratings Measurement Period Is Underway

The 2025 Star Ratings measurement period official kicked off on New Year's Day, 1/1/2023. Every year, the Centers for Medicare and Medicaid Services ("CMS") measures the performance of Medicare Advantage Organizations ("MAO") against Star measures across multiple datasets.¹ Different measures have different weights, with the overall calculation based on a weighted average.² Each metric is measured on a relative basis to other contracts and not to a predetermined performance target.³ Star thresholds, or cut points, are determined using algorithms based on data collected from all qualified contracts, which are then used to determine relative performance.⁴

The 2025 Star Ratings are based on the 2023 measurement period ("MY 2023"), which captures health services primarily provided between 1/1/2023 and 12/31/2023.⁵ In this article, we discuss the 2025 Star Ratings landscape including Star cut points, guardrails, new Star measures and increased weights reflecting member experience measures like the Consumer Assessment of Healthcare Providers and Systems program ("CAHPS").

Star Cut Points Move to the Right

For the bulk of the Star measures during the 2020 and 2021 measurement years, a greater number of cut points have decreased than increased, indicating an overall decline in performance across the industry.⁶

In a previous article published November 3, 2022, we discussed how the medication adherence measure cut points keep going up.⁷ For the measurement year 2020 (i.e., 2022 Star Ratings), CMS permitted removing "refill too soon" edits, which pushed health plans consider steps to enable programs like home delivery. As a result of those modifications, some higher cut points for these measures increased by four- or five-points last year.

CMS continues to weigh these adherence measures significantly.⁸ Therefore, for health plans, these adherence measures should continue to be at the top of their Stars strategy. Year-over-year, these measures have seen an inch-by-inch progression. Thus, it is safe to assume this trend will continue next year with at least a one percentage point increase in the cut points for medication adherence measures.⁹

Some measures that may prove challenging in 2023 include colorectal cancer screening ("COL"), which increased at every star cut point, notably two- and three- star cut points, causing additional challenges for health plans.¹⁰ One strategy for health plans would be to include an in-home FOBT/FIT kit to target currently enrolled members that were non-compliant in the prior measurement year with more frequent and high-touch outreach in Q1 2023.

Like the COL measure, the Medication Therapy Management ("MTM") program completion rate for Comprehensive Medication Review (CMR), also increased at every star cut point- a large 21 point increase for the Two-Star cut point and an 11 point increase for the Three-Star cut point.¹¹ Health plans that use MTM vendors for member outreach should consider a new approach to gap closures, one that focuses on hard to reach members having an in-house health plan pharmacist conduct outreach for MTM gap closure.

Guardrails Limit Cut Point Movement for 2025 Star Ratings

The 2022 Star Ratings was the first time that CMS used guardrails to increase the stability and predictability of measure level cutoffs. These barriers prevent non-CAHPS measure cut points from moving more than 5% in each direction.¹² Due to the CMS-imposed guardrails, it is important to keep in mind that changes in contract-level performance may have called for a larger cut point movement.

Thankfully, it is not all bad news. With guardrails in place, plans can now better predict their Stars performance on each measure and incorporate more fine-tuned strategies to achieve their desired Star Rating.

Tukey Outlier Elimination - Challenge to Keep Up with Future Star Ratings

Starting with the 2024 Star Ratings (2022 measurement period), CMS made it more difficult for plans to meet the performance standards necessary to retain or raise Star Ratings by removing performance outliers of non-CAHPS measures from the Tukey methodology's calculation of Star Rating cut points. This is because among contracts with poor performance, outliers are more frequently identified towards the bottom end of performance.¹³

While adjustments to the cut points might provide some perspective on the overall market Star Rating performance, it is vital to keep in mind that significant program and regulatory changes are also likely to affect an MAO's Star Rating performance.

Changes to Star Measures for 2025 Star Ratings (MY 2023)

In January 2021, the CMS Final Rule included the following measures in the 2024 Star Ratings calculation as 1x weight each: Transitions of Care and Follow-Up After Emergency Department Visit for People with High-Risk Multiple Chronic Conditions and brought back Plan All-Cause Readmissions as a Star measure¹⁴ (note: for 2025 Star Ratings – MY 2023, CMS has indicated this measure weight will increase to 3x¹⁵). CMS also confirmed the Breast Cancer Screening measure will remain as a Star measure, as the transition to the electronic clinical data systems ("ECDS") reporting is a non-substantive measure change since the measure specification and data sources have not changed from prior years.¹⁶

Transitions of Care now includes four indicators, and the Star measure will be an average of all four: Medication Reconciliation Post-Discharge, Notification of Inpatient Admission, Patient Engagement After Inpatient Discharge and Receipt of Discharge Information. Previously, CMS only included the Medication Reconciliation Post-Discharge as the Star measure.¹⁷ With the shift to now include all four indicators, the overall Star Ratings may see a negative impact, as two of these care gaps (Notification of Inpatient Admission and Receipt of Discharge Information) can only be closed during a medical record review and no claims data can be used to meet measure compliance.

Health Plans have previously pushed back on the original proposal when released in 2020; however, CMS recently highlighted the importance of adding all four indicators of the Transition of Care measure. "Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs."¹⁸

Member Experience & Access to Care Measures at 4x Weight

In June 2020, the CMS Final Rule made the Member Experience and Access to Care measures the most highly weighted non-improvement measures under the Overall Star Rating, increasing the measure weights from 2 to 4.¹⁹ Member Experience measures are captured through the CAHPS member survey which focuses on healthcare experiences and quality aspects that a member finds important and is well equipped to assess. Access to Care measures reflect issues that may create barriers to receiving needed care. Although the overall effect of this modification is projected to be positive, there may be considerable performance fluctuation at the CAHPS contract level rates, which could result in decreased Star Ratings performance for some MAOs.

Summary

Many MAOs that used the "best of" technique from prior years are likely to see reduced Star Ratings for 2025 if they do not alter their strategy. The financial cost may be significant, especially for plans that experienced diminishing performance quality during the pandemic. Although the trend for more challenging Star cut points each year is not new, plans should anticipate the increased difficultly and act sooner rather than later.

In addition, plan ratings will no longer be boosted by underperforming plans following the new Tukey outlier removal methodology effective with Star Rating year 2024 (based on measurement year 2022). The good news is that MAOs will not have to estimate which cut points will vary significantly since new guardrails will limit those changes for the 2025 Star Ratings. This guardrail stability will result in an increase in the return on investment for non-CAHPS measure enhancements. The guardrail clause does not apply to CAHPS measures, and these measures will continue with a weight of 4 for 2025 Star Ratings. Therefore, investments in these measures will remain crucial for your MAO's Stars strategy.

Footnotes

1. "2023 Medicare Advantage and Part D Star Ratings," Centers for Medicare & Medicaid Services, Office of Communications (October 6, 2022), https://www.cms.gov/files/document/2023-medicare-star-ratings-fact-sheet.pdf.

2. "Chapter 8: Redesigning the Medicare Advantage quality bonus program," MedPAC Report to the Congress: Medicare and the Health Care Delivery System, MedPAC (June 2019), https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/jun19_ch8_medpac_reporttocongress_sec.pdf.

3. Ibid.

4. "Trends in Part C & D Star Rating Measure Cut Points," Centers for Medicare & Medicaid Services (February 3, 2023), https://www.cms.gov/files/zip/cut-point-trends.zip.

5. "2023 Medicare Advantage and Part D Star Ratings." CMS.gov Newsroom. (October 6, 2022). https://www.cms.gov/newsroom/fact-sheets/2023-medicare-advantage-and-part-d-star-ratings

6. "Increased Weights, Cut Points Likely Led to Drop in 2021 Stars," Healthmine, Inc. (reprinted with AIS Health permission from the October 15, 2020 issue of RADAR on Medicare Advantage) (October 15, 2020), https://www.healthmine.com/resources/news/ais-health-increased-weights-cut-points-2021-medicare-advantage-star-ratings-drop.

7. Star Ratings: What's Ahead. FTI Consulting. (November 3, 2022). https://www.fticonsulting.com/insights/articles/star-ratings-whats-ahead

8. "4 Elements of a Successful Medication Adherence Strategy," RxAnte (Last visited January 21, 2023), https://www.rxante.com/health-plans/4-elements-of-a-successful-medication-adherence-strategy/.

9. "Trends in Parts C & D Star Rating Measure Cut Points. Centers for Medicare and Medicaid Services," Centers for Medicare & Medicaid Services (December 13, 2021), https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin/performancedata

10. "Medicare 2023 Part C & D Star Ratings Technical Notes," Centers for Medicare and Medicaid Services, Center for Medicare (Updated January 19, 2023), https://www.cms.gov/files/document/2023-star-ratings-technical-notes.pdf.

11. Ibid.

12. Calculation of Star Ratings, 42 C.F.R. § 422.166 (2022). Cornell Law School: Legal Information Network, https://www.law.cornell.edu/cfr/text/42/422.166.

13. "3 Impacts of COVID-19 on Your Star Rating Strategy," Outcomes MTM, A Cardinal Health Company (Last visited January 25, 2023), https://outcomesmtm.com/wp-content/uploads/2021/06/Star_Rating_Cut_points_whitepaper_final.pdf.

14. "Medicare and Medicaid Programs; Contract Year 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly," Federal Register (Last visited February 8, 2023). https://www.federalregister.gov/d/2021-00538

15. "Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021", Federal Register (Last visited February 8, 2023). https://www.federalregister.gov/d/2019-06822

16. "2024 Advance Notice". Centers for Medicare and Medicaid Services (last visited February 8, 2023). https://www.cms.gov/files/document/2024-advance-notice.pdf

17: Ibid.

18: Ibid.

19: "2021 Medicare Advantage Star Ratings Changes and CAHPS Improvement," Adhere Health (December 3, 2020), https://adherehealth.com/2021-medicare-advantage-star-ratings-changes-and-cahps-improvement/.

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