For health plans navigating the Medicare Advantage landscape, the annual CMS Star Ratings are less a report card and more a high-stakes survival guide. A fractional change in a plan’s score can trigger millions in bonus payments or losses, and swing enrollment by the thousands. With ratings recently seeing a significant drop and CMS shifting its priorities toward clinical outcomes, the pressure to adapt has never been more intense. To unravel what this means for plans on the ground, we’re speaking with James Maitland, a recognized expert who has spent his career dissecting the complexities of health plan performance and the pivotal role of the Star Ratings system.
The article highlights that a jump from a 3-star to a 4-star rating can boost revenue by up to 17.6%. Considering that the number of 4-star plans recently dropped significantly, could you provide a step-by-step breakdown of how that revenue increase actually materializes for a plan?
That 17.6% figure is a powerful motivator, and it’s not just an abstract number; it’s the result of several concrete financial levers being pulled simultaneously. First and most directly, you have the Quality Bonus Payments. Plans that achieve a rating of 4 stars or higher receive a 5% upward adjustment to their reimbursement rate for the following year. This is a direct injection of capital that can be reinvested into member benefits or operational improvements. Second, there’s the enrollment engine. A 4-star rating is a powerful marketing tool that can drive an 8-12% increase in new members. Beneficiaries see that star rating on the Medicare plan finder, and it acts as a trusted seal of approval, making your plan far more attractive. Finally, and this is often overlooked, 4- and 5-star plans gain access to special enrollment periods, allowing them to sign up new members year-round. This is a huge competitive advantage. So, you’re not just getting more money per member; you’re also attracting and retaining more members, which compounds that revenue growth dramatically.
With CMS increasing the weight of clinical outcomes measures, the content states that relying on claims data is “already too late.” What practical, alternative strategies should health plans implement to proactively manage care and improve performance on these newly prioritized clinical measures? Please provide specific examples.
That phrase, “already too late,” really hits home because claims data is fundamentally a rearview mirror; it tells you what happened weeks or even months ago. To succeed now, plans must shift to a predictive and real-time model. A crucial strategy is investing in data interoperability that provides immediate event notifications. Imagine a member is discharged from a hospital. Instead of waiting for a claim, the plan gets an alert within hours. This allows a care manager to immediately initiate a follow-up, schedule a doctor’s visit, and perform medication reconciliation—all critical actions that are measured by time-bound HEDIS metrics. Another practical strategy is to leverage predictive analytics to identify at-risk members before a negative event. By analyzing a combination of clinical data, past utilization, and even social determinants of health, you can pinpoint a member who is, for instance, at high risk for a hospital readmission. You can then deploy proactive case management and resources to that individual, preventing the adverse event rather than just reacting to the claim after it happens.
The piece mentions that collaboration between health plans and providers is more important than ever. Can you describe what an ideal, highly-effective partnership looks like day-to-day and share an anecdote where this type of collaboration directly prevented a potential care gap?
An ideal partnership feels less like a contract and more like a shared nervous system, with information flowing freely and instantly in both directions. On a day-to-day basis, this means moving beyond fax machines and phone tag to a shared, real-time data platform. The plan’s care manager and the provider’s office are looking at the same patient dashboard, seeing the same alerts for ER visits or hospital discharges. I remember one case vividly: an alert fired that an elderly member with several chronic conditions had been discharged. The plan’s care manager saw it instantly and noticed that no follow-up appointment was scheduled. She immediately contacted the primary care provider, who, because they were on the same platform, could see the discharge summary and coordinate a telehealth visit for the next morning. Without that seamless, real-time connection, that member could have easily fallen through the cracks, confused about their new medications and ending up right back in the hospital. That’s the kind of gap that technology-enabled collaboration can close before it even truly opens.
Star Ratings are a complex blend of measures, including plan administration and member satisfaction. What are the most common operational missteps you see that cause plans to lose points on these administrative measures, and what key metrics should they track to stay ahead of potential problems?
It’s a mistake to focus solely on clinical measures and forget that a huge part of the rating is based on the member’s experience. One of the most common missteps I see is treating the call center as a simple cost center. Long hold times, poorly trained staff, and the inability to resolve an issue on the first call are absolute poison for member satisfaction scores. Members feel ignored and frustrated, and that shows up in surveys. Another major pitfall is a reactive approach to case management. Plans wait for a member to get sick or complain before engaging, but high-performing plans are proactively reaching out to manage chronic conditions and ensure smooth care transitions. To stay ahead, plans must obsessively track metrics beyond the basics. They need to monitor first-call resolution rates, average call handle times, member complaint trends, and, most importantly, member retention rates. A dip in retention is a massive red flag that your administrative and customer service functions are failing to meet expectations.
What is your forecast for how the Star Ratings system will evolve as CMS pushes toward its goal of 100% of Medicare patients being in value-based care plans by 2030?
As we accelerate toward that 2030 goal, the Star Ratings system will become even more dynamic, more demanding, and more deeply integrated with real-time clinical reality. I predict we will see a much stronger emphasis on health equity measures, where plans will be explicitly scored on their ability to close care gaps and improve outcomes for underserved populations. Furthermore, the reliance on claims data will continue to diminish, replaced by a greater expectation for direct data integration from electronic health records and other clinical systems. This will make the ratings a truer, more immediate reflection of care quality. Finally, as more plans improve their performance, the bar for excellence will keep rising. I expect CMS will tighten the “cut points,” making it significantly harder to achieve those coveted 4- and 5-star ratings. The future of Star Ratings is one of continuous improvement, where coasting is not an option and success will belong only to those plans that fully embrace a proactive, data-driven, and truly member-centric approach to care.
