How CMS could better support health in Medicare Advantage – the health care blog

By Emmanuel Animashaun
The system of stars of centers for Medicare & Medicaid Services (CMS) represents a cornerstone of the quality assessment in Medicare Advantage (MA), designed to allow consumers of power of transparent information while rewarding plans which offer superior care. However, recent developments, in particular the seismic demotion of humana notes, reveal an involuntary consequence: a system created to measure and encourage quality can now actively undermine.
The Humana case: symptom of a wider problem
In 2025, the notes of Star Medicare Advantage of Humana collapsed, with only 25% of the members remaining in four -star or more plans, against 94%. This was not due to the drop in clinical performance, but results from the statistical adjustment of the “aberrant abolition of the aberrant value” of CMS implemented with a minimum consultation of the industry. The change has increased the performance thresholds, which means Humana loses billions of quality premium payments and $ 4 billion in market value. Humana’s judicial challenge, arguing that the CMS violated the administrative procedure law through non -transparent processes, has been refused. Other insurers, including Unitedhealthcare and Centene, also share concerns about methodological rigidity and that the rating system may have diverged its objective of improving patient care.
Perhaps more striking are the cases of elevation and scan, which also illustrate how rigid measurements can distort the real quality assessments of care. In March 2023, the two insurers were penalized after allegedly missing a single telephone call “Secret Shopper”, an appeal they claim have never been received. The demotion cost them tens of millions of quality premium payments and triggered legal challenges. As the CEO of Scan wrote, the sanction has occurred despite solid clinical performance and results for patients. A federal judge then ruled in favor of Scan in June 2024, which prompted CMS to recalculate the notes of the stars in all the Medicare ads. This episode highlights a key concern: when the measure depends on the unverifiable administrative moments, it can eventually punish rather than promote quality.
How the quality measurement can undermine the real quality
The Star rating system is full of 40 measures between preventive care, medication membership, members’ experience and customer service. However, it disproportionately rewards compliance and documentation of processes on health results. Plans can excel by optimizing coding, maximizing documentation or stimulating the participation of the survey without providing better care. This disalcher diverts the resources of real health innovations. The research of a working document has even revealed that the better rated plans are not statistically better to maintain patients alive than those with lower evaluation, which raises fundamental questions as to whether the system measures which really counts for the health of patients.
Even more worrying is that the contracts of MA with higher proportions of eligible, disabled or diversified duplicate limbs, not systematically lower, not because they provide lower care, but because the rating system adapts inadequately for social risk factors. A study of the Jama Health Forum underlined how the plans serving more black beneficiaries had lower stars notes, even during the control of other factors. This structural bias effectively penalizes plans doing difficult work to serve populations with complex needs, creating perverse deterrence to focus on health equity.
The uncertainty of frequent changes in the calculation of stars evaluation could also make serious implications for strategic planning for companies. When a company like Humana loses billions due to technical recalibration, it sends a disturbing message: long -term investments in quality improvement may not produce yields if measurement methodologies change unpredictably. This volatility makes strategic planning difficult and discourages supported investments in quality initiatives.
The impact of the real world on patients
These methodological shortcomings not only affect the results of health plans; They have tangible consequences for the beneficiaries of Medicare. When plans lose quality premium payments (QBP), they often have to reduce precious additional advantages such as transport aid, dental coverage or home support services, or increase plan bonuses, as Health suggests. McKinsey estimates that CMS rating changes could cost plans over $ 800 million in bonuses, reducing the resources available for such advantages.
In addition, rating fluctuations can trigger an unnecessary change in plan as members, confused as to whether the lower stars indicate poor quality, change plans unnecessarily. These transitions often disrupt relationships with established providers and care management programs, potentially harming clinical results. Research shows that disturbances in relations with providers lead to a reduction in the use of primary care, an increase in visits to emergency services and higher hospitalization rates, in particular for vulnerable populations with chronic conditions.
In addition, the plans may hesitate to manage new approaches to manage populations at high cost and high risk if demographic realities mean that they could always face rating penalties despite clinical success. This frightening effect on innovation ultimately affects beneficiaries who could the most benefit from creative care models, strengthening a system that rewards standardization in relation to significant improvements in the provision of care for complex populations.
A framework for a significant reform
To restore the alignment of the stars’ rating system to improve quality care for Medicare beneficiaries, four essential reforms are necessary:
1 and 1 Stabilize methodology and improve transparency: The CMS should only introduce methodological changes after a robust public opinion, a significant commitment to stakeholders and adequate implementation deadlines. Transparency in the development, weighting and adaptation of measures is fundamental to maintaining the system confidence and allowing plans to align their quality strategies accordingly.
2 Implement a complete social risk adjustment: The current categorical adjustment index has shown a modest impact. A more equitable evaluation system must take into account in -depth accounts of income disparities, disability status, race, linguistic barriers and other social factors influencing the service and results of care. This adjustment recognizes the additional resources necessary to obtain equivalent results for populations with complex social needs.
3 and 3 Reorient significant results: Emphasis should evolve towards measurable health improvements as a reduction in hospitalizations and better management of chronic diseases, rather than focusing strongly on process measures or survey results that may not be correlated with real health benefits.
4 Reward innovation and health equity efforts: The CMS should recognize that plans make significant investments in the fight against health disparities and the creation of innovative care models for poorly served communities.
The Humana affair, alongside the disturbing incident of telephone calls and elevance, represents a critical inflection point for the measure of the quality of Medicare Advantage. When a single missed call can trigger devastating financial penalties despite high clinical performance, and when plans serving millions of beneficiaries can lose billions of day -to -day value due to methodological changes rather than real care deficiencies, the system has clearly lost sight of its objective.
By implementing the proposed reforms, the CMS can transform the stars’ notes of a compliance exercise into a real catalyst for better patient care. The ultimate measure of success should not be statistical perfection or adherence to rigid administrative protocols, but that the system helps elderly people vulnerable to live healthier, longer lives while reducing the disparities in the quality of care. It is only then that the stars’ assessments will fulfill their planned role: to guide the beneficiaries towards really superior plans while rewarding insurers who excel in improving health, not only compliance.
Emmanuel is a doctor from Nigeria and a second -year MPH / MBA candidate at the Johns Hopkins Bloomberg School of Public Health and Carey Business School. His work focuses on financing health, delivery reform and strategic approaches to the transformation of health systems.