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I guess I am the bearer of bad news on Star. Fresh off some very bad news for Star Year 2025, unfortunately I am here to tell you that Medicare Advantage (MA) plans will continue to struggle into the future unless they right their Stars ships quickly. Here are some major changes that are already in regulation. Let’s remember that the Biden administration is accelerating 2026 rule-making. In the coming weeks we could learn of additional changes in future Star years. What changes are slated for Star so far? 📲MY 2024/SY 2026 saw the first true NCQA electronic measure in Stars known as ECDS. This is Colorectal Cancer Screening (I don’t count Breast Cancer Screening for SY 2025 as it was not a hybrid measure). More will roll out over time. I predict that plans will see majro reductions in Collrectal Cancer Screening for SY 2026 because of the conversion. 📲A new Kidney Health Evaluation for Patients with Diabetes measure comes in for MY 2024 for SY 2026 and beyond. 📲Patients’ Experience and Complaints and Access measures weights drop from 4 to 2 weights for SY 2026. Depending on current performance, this could help some plans but hurt others. The drop in the measure weights effectively shifts the relative importance of these measures to clinical and drug measures. 📲 We have two new drug measures in SY 2027 (COB and Poly-ACH), and we can expect more in the future. Drug measures have been tough for plans. 💡 💡 💡 BIG TIP ON THE NEW DRUG MEASURES: if you have not been tracking and remediating COB and Poly-ACH, you need to look at your members' therapy in Q4 and push remediation ASAP to have a good compliance rate in 2025. Even a few claims over a 30-day period in MY 2025 could mean a member is non-compliant. 💡 💡 💡 📲 The returning HOS measures (Improving and Maintaining Physical Health and Improving and Maintaining Mental Health) for SY 2026 will be 3x weighted in SY 2027. HOS is a major trouble spot for MA plans. 📲 In 2027, the Health Equity Index is slated to award well less in the first few years than the existing Reward Factor. First you have to have enough Low Income Subsidy/Dual Eligibles/Disabled members. Then you have to be better at driving outcomes on these populations compared to the universe. So as you can see, the complexity and stress will only get worse for plans on Star. See our great data science Infographic on SY 2025 and historic years. Lilac now has a comprehensive database back to 2015 to track and trend Star performance and to forecast future cut points. Lilac Software Infographic: https://lnkd.in/eVRcUwwd Need help on Stars, please reach out to me. Our technology and expertise can help you drive to and maintain 4 Stars or greater. #cms #stars #quality #medicareadvantage Lilac Software

More on 2025 Stars ... Medicare Advantage (MA) plans had tremendous success driving some Star Year 2025 measures and major difficulty with others. Far more contracts struggled with major declines than drove major improvements, which is consistent with the overall drop in Star scores. See the image below and “Data Deep Dives” in our Infographic here: https://lnkd.in/eVRcUwwd More plans seemed to have success driving results for the following: 🔼 Transitions of Care 🔼 Plan All-Cause Readmissions 🔼 Medication Adherence for Statins 🔼 Getting Appointments and Care Quickly 🔼 Rating of Health Care Quality 🔼 MTM Comprehensive Medication Review 🔼 Rating of Drug Plan 🔼 Follow-up Emergency Department The movement on Transitions, Readmissions, and Follow-up ED is a good sign as these have been major struggle points for plans. Along with Medication Reconciliation (going away soon as a separate measure but still within Transitions), these are what I call the complex clinical or event-based measures that are so complex and have quick turnarounds to comply. The two improvement measures also moved up for many plans. On the flip side, more plans struggled with the following: 🔽 The two Call Center measures 🔽 Controlling Blood Pressure 🔽 MPF Price Accuracy 🔽 Drug Plan Quality Improvement 🔽 Colorectal Cancer Screening 🔽 Diabetes Care Eye Exam 🔽 Breast Cancer Screening 🔽 Reducing the Risk of Falling 🔽 Stain Therapy for Cardiovascular Disease. The Call Center measures are very controversial for the small number of qualifying events and discretion the Centers for Medicare and Medicaid Services (CMS) has in assessing the measures. In Star Year 2024, Elevance Health successfully litigated a change in its Call Center scores. United Healthcare, Humana, and Centene are all appealing and suing CMS this year on Call Center metrics. Elevance Health could join again. #cms #stars #medicareadvantage Lilac Software The Healthcare Labyrinth

Continuing my review of Star Year 2025 data, average scores for measures are mixed from 2024 to 2025. From 2024 to 2025, 19 measures saw their scores drop, 16 saw them increase, and 7 saw them stay the same. See “Average Star Rating By Measure” in our Infographic here: https://lnkd.in/eVRcUwwd . If almost as many measures went up and down, why such a major drop in overall scores? Because 11 of the 19 measures that went down had weights of 3, 4, or 5. In terms of those that improved, just 8 had weights of 3, 4 or 5. It is also true that measures that declined collectively had bigger drops than those that increased. The 5x-weighed Part C improvement measure did leap from 2.9 to 3.6 from 2024 to 2025, with the 5x-weighed Part D improvement measure dropping from 3.4 to 3.3 from 2-24 to 2025. But the Part C improvement leap was not enough to offset the overall Star rating drops. In the end, Star is a complex mix of new and old measures, changing weights, and trying to always prognosticate how you are doing against your peers overall. It is not for the faint of heart. #cms #stars #medicareadvantage #quality Lilac Software

Humana Has Made Some Good Points In Its Star Lawsuit In the broadest lawsuit yet over Star scores, Humana has sued CMS over its 2025 Star ratings. Lawsuits in 2024 from Scan and Elevance Health and in 2025 from United and Humana are relatively tame compared with Humana's. They argued specific points of regulation or on a specific measure or measures. United uses words like “arbitrary" and "capricious” in detailing its lawsuit, but the Humana suit argues that in spades compared with United. Humana argues that the entire Star program is administered in an arbitrary and capricious manner in violation of the Administrative Procedures Act. Humana says CMS is not following its own regulations by not disclosing all Star ratings calculation criteria or responding adequately to data discrepanices reported by the plan. United limited its suit to one customer service phone call that impacted its ratings. Humana’s lawsuit argues three phone calls were scored unfairly. The Humana lawsuit is a gamble but not necessarily unreasonable. The argument is not wrong that CMS has data miscalculations and discrepanices and does not adequately disclose all the information plans need to calculate their own Stars to assess where they are. Good examples are: — Critical improvement measure information is received only during Plan Preview 2. — The consumer assessment (CAHPS) and health outcome (HOS) surveys are fully anonymized and plans must trust CMS and its vendor to choose samples that meet enrollment criteria and then calculate all factors and scores correctly. The CAHPS case mix adjustment is a black box as well. — There have been reports of inaccurate designation of Low Income Subsidy (LIS) individuals, which impacts the Categorical Adjustment Index (CAI). — While certain Tukey information has been released, calculating cut points indeed has been a challenge. Humana says it could not replicate 60% of CMS’ cut point calculations after Star ratings were released and CMS was not disclosive when they asked the agency for additional information. The transparency demand is entirely reasonable in light of CMS’ reprimand by two federal court judges for blatantly ignoring the guard rail/cut point regulations. On the issue of call center measures, there seems to be inconsistency in how CMS and its vendor adjudicates TTY and foreign language services. Plans may be blamed for technological failures outside of their responsibility. Elevance Health won on these points last year. Capitol Hill will look at the reasons behind falling Star scores as well as whether the government is getting its value from MA rebates from the Star program. I have generally supported the Stars program and CMS' goal of continuous quality improvement. But Congress should also look at whether the Star program is being run fairly and transparently by CMS. Humana has made some very good points in its lawsuit. #cms #stars #medicareadvantage #partd #humana The Healthcare Labyrinth Lilac Software