Medicare Advantage (MA) Star Ratings influence billions of dollars in bonus payments and health plan enrollment. Current approaches to accounting for enrollee social risk may not fully capture differences in beneficiary populations.
Study Design and Methods
This study assessed how MA contract performance rankings for statin receipt and adherence change under a social risk–weighted scoring approach. The study used a cross-sectional analysis of 2019 MA data to evaluate how contract-level performance groupings change under social risk–weighted scoring.
Contract-level social risk–weighted performance scores were calculated using a previously proposed constrained optimization framework.
Results
Social risk–weighted scoring reclassified 24.2% of contracts for statin receipt and 20.6% for statin adherence. For statin receipt, 11.5% of contracts moved up, 12.7% moved down, and 75.8% were unchanged. For statin adherence, 7.3% moved up, 13.3% moved down, and 79.4% remained the same.
Predictors of performance scores included disability prevalence. Each 1–percentage point increase in disability prevalence corresponded to a 0.7–percentage point higher probability of receiving 3 or fewer stars for statin receipt and a 1.3–percentage point higher probability for adherence. Larger contracts also had lower predicted probabilities of receiving 4 stars, decreasing by 3.4 percentage points for receipt and 3.8 percentage points for adherence per 1-unit increase in log enrollment.
Conclusion
Incorporating social risk–weighted scoring meaningfully reclassified MA contract rankings for statin receipt and adherence. This approach provides policy makers with a framework to better align incentives with the challenges faced by health plans serving high-need populations.
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Social risk weighting can help reduce the influence of population differences on contract comparisons. However, the effects of social risk weighting were more pronounced for statin adherence than for statin receipt.
As the Centers for Medicare and Medicaid Services continues efforts to modernize Star Ratings, constrained optimization–based weighting could help redesign plan evaluations to address the influence of social risk in performance measurement.
Medicare Advantage (MA) performance ratings determine eligibility for billions in quality bonus payments annually, directly influencing the resources that plans can invest in supplemental benefits such as meals, transportation, and housing support for populations with greater health and social needs. Yet concerns remain that the Star Ratings program insufficiently adjusts for social risk factors, systematically disadvantaging plans that serve a higher proportion of beneficiaries with disabilities, low incomes, and other barriers to care.
CMS modernization efforts, including Excellent Health Outcomes for All, reflect growing recognition that fair plan comparisons depend on accounting for social risk in performance measurement. This shift moves beyond secondary, post hoc adjustments toward stronger, goal-aligned incentives within MA.
Although some performance measures are adjusted for clinical complexity, others, including statin receipt and adherence, are not routinely adjusted for enrollee characteristics, despite being influenced by both clinical and social risk. In response to fairness concerns, CMS introduced the Categorical Adjustment Index (CAI) in 2017, which provides a bonus to contracts serving higher proportions of beneficiaries with dual eligibility or disability.
Takeaway Points Medicare Advantage Star Ratings influence billions in payments, yet they may penalize plans serving high-need populations. Social risk weighting reclassified 20% to 24% of contracts across the statin receipt and adherence measures. Performance rankings changed modestly, with approximately 1 in 5 contracts moving up or down a performance ranking. Social risk weighting did not uniformly raise ratings for contracts serving high–social risk populations. In several cases, contracts with lower proportions of dually eligible or disabled enrollees moved up in relative ranking.
