Abstract
BACKGROUND:
The Medicare Star Ratings Program, managed by the Centers for Medicare & Medicaid Services, assesses Medicare health plan performance. This program consists of quality measures that evaluate plan performance for both Medicare Part C and Part D, including 3 key medication adherence measures.
OBJECTIVE:
To assess the potential relationship between performance on medication adherence measures and overall star rating performance for Medicare Advantage (MA) health plans.
METHODS:
An analysis was conducted using annual Medicare Star Rating health plan performance data from 2015 to 2024 to assess the impact of performance on medication adherence measures on health plan overall star rating. Numerical percentages were calculated to assess the rates of a health plan achieving at least a 4-star overall rating if they achieved 4 or more stars, as well as a 5-star rating on each medication adherence measure or composite measure.
RESULTS:
From 2015 to 2024, 4,213 health plan contracts received a star rating, of which 2,076 achieved at least a 4-star overall rating (49.3%). For plans achieving at least 4 stars on the medication adherence measures, 70%-74% of them also achieved at least a 4-star overall summary rating, depending on the specific measure. Among plans achieving 5 stars on any adherence measure, 85%-90% of them achieved at least a 4-star overall rating.
CONCLUSIONS:
Assessing a decade of the Medicare Star Rating performance data showed that MA health plans that performed well on the medication adherence measures also had a high rate of achieving a 4-star overall rating. Future research should explore the interplay between medication adherence measures and other Medicare Star Rating criteria.
Plain language summary
Over the last 10 years, Medicare Advantage health plans that demonstrated high performance on the Medicare Star Ratings adherence measures had higher rates of achieving at least a 4-star overall summary rating. The better a health plan performed on these adherence measures, the higher the rate of achieving high overall ratings.
Implications for managed care pharmacy
Strong performance on the Medicare Part D Star Rating medication adherence measures leads to higher rates of Medicare Advantage health plans achieving at least a 4-star overall summary rating, earning higher rebates, and qualifying for quality bonus payments. This shows a potential role of medication adherence in health plan performance and financial outcomes. Health plans should consider initiatives that support medication adherence to achieve these benefits.
The Medicare Star Ratings program was established in 2007 by the Centers for Medicare & Medicaid Services (CMS) to evaluate the quality of Medicare health plans annually based on selected quality measures. 1 The program includes quality measures that assess health plan performance for both Medicare Part C and Medicare Part D. Each measure is assigned a weight ranging from 1 to 5. 2 These measures are used to calculate the health plan’s Part C summary rating, Part D summary rating, and overall summary rating. Summary ratings range from 1 to 5 stars, increasing in increments of 0.5 stars. The measures included in the star ratings are reviewed and updated regularly, allowing for potential variability in both included measures and their weights each year. For the 2024 Medicare Star Ratings, there were 30 Part C measures and 12 Part D measures, totaling 42 measures. 2 The cut-point thresholds for each star rating for every measure vary year to year. Medicare Advantage prescription drug (MAPD) plans receive a Part C summary rating and a Part D summary rating, which combine to form the overall summary rating.
Performance on star ratings has been associated with improved health outcomes for patients in high-performing plans. 3 – 6 An analysis of CMS data from 2014 to 2015 found that 1-star increases in overall star rating had a 0.5–percentage point (pp) significant reduction in 90-day readmissions (P < 0.001) and a 0.3-pp nonsignificant reduction in 30-day readmissions. 3 The same study showed that 1-star increases in overall star rating resulted in significantly higher management of blood pressure (5.3 pp), colorectal cancer screening (3.6 pp), breast cancer screening (1.8 pp), and primary care visits (0.5 pp). 3 Additionally, a study examining Medicare data from 2010 to 2016 found that patients who were adherent to their Part D adherence measure medications also had increased adherence to their nontargeted medications. 4
Medicare Star Ratings performance is important for MAPD plans because of its financial implications. Plans achieving an overall summary rating of 4.5 or 5.0 stars receive a 70% rebate from CMS, those with 3.5 or 4.0 stars receive a 65% rebate, and plans with less than 3.5 overall stars receive a 50% rebate. 7 Additionally, health plans that receive at least a 4.0-star overall rating qualify for a 5% quality bonus payment (QBP). 7 In 2024, Medicare paid more than $11.8 billion in QBP to MAPD plans, with the average QBP per enrollee ranging from $265 to $516, depending on the specific plan. 8 Furthermore, increases in health plan star ratings have been associated with increased health plan enrollment and revenue. 9
Three Part D measures focus on medication adherence, specifically to noninsulin antidiabetics, renin-angiotensin system antagonists (RASAs), and statins, with all 3 measures having a weight of 3. 2 These adherence measures are based on the percentage of health plan members on each medication class achieving an adherence of at least 80% proportion of days covered within the calendar year. 2 For MAPD plans, the adherence threshold of achieving 5 stars has been rising annually, from at least 81% of members for noninsulin antidiabetics, 85% of members for RASA, and 83% of members for statins in 2015 to 90% of members for noninsulin antidiabetics, 91% of members for RASAs, and 91% of members for statins in 2024. 2 , 10
Medication adherence is an important determining factor in treatment success across many disease states and medications, and this is true for the 3 Medicare Star Ratings adherence measures. Research shows that Medicare patients who are adherent to RASAs, statins, and/or noninsulin antidiabetics have better health outcomes and lower health care costs and health care resource utilization. 5 , 11 , 12 There may be additional benefits seen by health plans with patients adherent to their medications, such as a positive correlation between performance on medication adherence measures and performance on Part C intermediate measures (ie, controlled blood glucose and controlled blood pressure). 13 In addition, research has shown that patients who are adherent to their medications have higher quality of life (QoL), which has been linked to improved outcomes. 14 – 17 Considering the advantages a health plan might gain from enhanced medication adherence, it is important to assess whether improved adherence is associated with differences in overall Medicare Star Rating performance. Therefore, this study evaluates the potential relationship between performance on medication adherence measures and overall star rating performance for MAPD plans.
Methods
STUDY DESIGN
A cross-sectional analysis was conducted using the publicly available annual Medicare Star Ratings health plan performance data of all Medicare contracts from 2015 to 2024 to assess the impact of performance on medication adherence measures on MAPD plan overall star rating. 18 Plans were included on an annual basis and were considered independent from their prior or future years’ performance in the analysis. Each year, plans were excluded if their overall star rating was “not applicable,” “not enough data available,” or “plan too new to be measured.”
OUTCOMES
The primary outcomes were the percentages of plans that achieved at least a 4-star overall summary rating after attaining 4 stars or 5 stars on a medication adherence measure. The 4-star threshold was chosen in the analysis for the overall rating assessed because a 4-star overall rating is needed to receive a QBP. Outcomes were assessed for each medication adherence measure individually (RASAs, statins, noninsulin antidiabetics), as well as for composite outcomes of only 1 medication adherence measure,only 2 medication adherence measures, and all 3 medication adherence measures. Results were calculated for each calendar year and for the cumulative 10-year period. Chi-square tests were conducted to compare the statistical differences between plans achieving at least 4 stars on the medication adherence measures and those achieving 5 stars, assessing their respective percentages of attaining a 4-star overall summary rating. 19 Statistical significance was defined as a P value less than 0.05, and chi-square tests were conducted using MedCalc software. 20
To compare the impact of medication adherence measures on overall performance with other measures, we assessed all star rating measures over the 10-year period. Specifically, we examined the percentage of plans achieving at least a 4-star overall summary rating if they achieved at least 4 stars or 5 stars on the measure of interest. Owing to high potential of collinearity, statistical analyses and adjustments were not conducted, and the results are presented as a descriptive summary.
Results
From 2015 to 2024, a total of 4,213 health plan contracts received a star rating, of which 2,076 (49.3%) achieved at least a 4-star overall rating. For the diabetes adherence measure, 69.8% of plans that achieved at least 4 stars and 86.6% of plans that achieved 5 stars on the measure achieved at least a 4-star overall summary rating (P < 0.0001) (Figure 1). For the RASA adherence measure, 72.8% of plans with at least 4 stars and 85.4% of plans with 5 stars on the measure achieved at least a 4-star overall summary rating (P < 0.0001). For the statin adherence measure, 73.9% of plans with at least 4 stars and 89.6% of plans with 5 stars on the measure achieved at least a 4-star overall summary rating (P < 0.0001).
FIGURE 1.
Percentage of Health Plans That Achieved at Least 4 Stars or Achieved 5 Stars on the Medication Adherence Measures That Also Achieved at Least a 4-Star Overall Summary Rating
The percentage of 5-star ratings on measures that achieved at least a 4-star overall rating was significantly higher than the percentage of at least 4-star ratings on measures that achieved at least a 4-star overall rating with P < 0.0001 for every measure assessed in this figure.
These adherence measures were selected because of their demonstrated correlation with higher Medicare Star Ratings. The data illustrate that improved adherence significantly enhances the probability of achieving at least a 4-star overall rating. Additionally, achieving 5 stars on these measures increases the rate of a higher overall plan performance, highlighting the potential role of medication adherence in both clinical outcomes and financial incentives.
RAS = renin-angiotensin system.
The rate of achieving at least a 4-star overall summary rating was higher among plans that performed well on more adherence measures. This ranged from 37.7% of plans achieving at least 4 stars on only 1 measure to 80.0% of plans achieving at least 4 stars on all 3 adherence measures. Similarly, for plans achieving 5 stars on the adherence measures, 74.4% achieved at least a 4-star overall rating when 5 stars were attained on only 1 adherence measure, compared with 93.2% for plans achieving 5 stars on all 3 adherence measures. The rates of achieving at least a 4-star overall summary rating varied from year to year, and in 2024, plans achieving 5 stars on medication adherence measures had lower rates of achieving a 4-star overall summary rating (Supplementary Table 1 (230.2KB, pdf) , available in online article).
Medication adherence measures were associated with higher percentages of achieving at least a 4-star overall rating compared with most other star rating measures from 2015 to 2024 (Supplementary Table 2 (230.2KB, pdf) ). Plans achieving 4- or 5-star adherence ratings had higher rates of achieving high overall ratings. Only 1 measure surpassed the statin adherence measure, 2 measures exceeded the RASA adherence measure, and 5 measures exceeded the diabetes adherence measure in percentage of plans achieving at least a 4-star overall summary rating when achieving at least 4 stars on that measure (Figure 2). Although some measures had slightly higher numerical percentages, these differences were not statistically tested owing to potential multicollinearity, and results should be interpreted with caution when comparing with other measures.
FIGURE 2.
Rates of High Performance on Individual Star Rating Measures on Achieving at Least a 4-Star Overall Summary Rating
BMI = body mass index; CMR = comprehensive medication review; ED = emergency department; MPF = Medicare plan finder; MTM = medication therapy management; RAS = renin-angiotensin system; TTY = teletypewriter, w/ = with.
Discussion
Analyzing the Medicare Star Ratings data from the past 10 years, we found that health plans performing well on the medication adherence measures had a high rate of achieving at least a 4-star overall summary rating and, consequently, qualifying for a QBP. Additionally, plans that achieved at least 4 or 5 stars on the medication adherence measures had a numerically higher percentage of attaining at least a 4-star overall rating compared with most other star rating measures, although statistical significance was not assessed. This includes the 2 improvement measures that both have a weight of 5, as well as the 2 outcome measures of improving or maintaining physical and/or mental health, which had weights of 3. Although CMS periodically publishes an assessment of the impact of their quality measures, 21 they do not analyze how specific measures impact the overall performance of health plans. The findings from our analysis show that improving medication adherence may be associated with improved quality of care for patients.
Several factors may explain these results. First, there may be a potential relationship between performance on medication adherence measures and other Medicare star measures. 22 An analysis of the 2015 Medicare Star Ratings found positive associations with each medication adherence measure and their corresponding Part C intermediate outcome measures (controlled blood glucose, blood pressure, and cholesterol; of note, controlled cholesterol is no longer a Star Rating measure). 13 Each pp improvement of the adherence measures was associated with a 4.13 to 4.69 greater adjusted odds of being in the top quartile of the corresponding Part C intermediate measure. 13 In the 2024 star ratings, the 2 Part C intermediate outcome measures of controlled blood glucose and controlled blood pressure each have a weight of 3. 2 Additional measures that might have spillover effects include the Part C statin therapy for patients with cardiovascular disease (weight of 1) and the Part D measure of statin use in persons with diabetes (weight of 1 from star ratings years 2019-2020, and 2023 to present; weight of 3 from star ratings years 2021-2022). 2 Plans and payers that have high performance on the statin adherence measure may use targeted approaches to identify patients needing statin therapy and ensure that patients needing therapy are taking their medications appropriately.
Adherence to the Star Rating adherence medication classes of noninsulin antidiabetic medications, RASAs, and statins in the Medicare population has been associated with lower disease-specific and all-cause emergency department visits and hospitalizations, while also reducing health care costs. 5 , 11 , 12 The 2024 National Impact Assessment published by CMS showed that the increasing medication adherence is associated with improved outcomes. 21 They estimate that the increased medication adherence rates in the Medicare population in 2020-2021 led to health care cost avoidance of $11.6 billion for statins, $506 million to $1.8 billion for diabetes medications, and $12.4 billion to $15.7 billion for RASA. 21 Increased medication adherence has been correlated with a reduction in health care resource utilization and may also potentially influence the Part C outcome measure of all-cause readmissions, as research has shown medication nonadherence is a contributing factor to hospital readmissions. 23 , 24 Additionally, improving medication adherence to the Star Rating medications has been associated with higher adherence to other chronic medications such as β blockers, thiazides, calcium channel blockers, non-statin antihyperlipidemics, and levothyroxine, 4 ultimately resulting in better patient outcomes. 25
In addition to cost savings, improving medication adherence has significant humanistic benefits. Patients who are adherent to their medications generally report higher QoL than those who are not adherent, especially for those with diseases and conditions that the Star Rating medication adherence measures assess, such as diabetes, heart failure, and cardiovascular disease. 14 – 17 Higher medication adherence has been observed alongside indicators of higher quality of care, which this study helps to support. An analysis of Medicare data from 2007 to 2009 found that patients of physicians who had high adherence rates to diabetes and heart failure medications also had better health outcomes than patients of physicians with lower rates of adherence, suggesting adherence could be an indicator of quality of care. 26
Payers often use various interventions to improve medication adherence in their populations, such as 90-day prescription fills, 27 prescriber outreach, 27 , 28 patient outreach, 29 , 30 refill reminders, 29 , 30 and medication therapy management (MTM). 28 , 31 Health plans focusing on and utilizing MTM can improve medication adherence and impact the Part D process measure of MTM program completion rate for comprehensive medication review (weight of 1). 2 This analysis demonstrates that improving medication adherence for a health plan may be associated with additional clinical and financial gains, making investment in adherence improvement initiatives a potential worthwhile endeavor.
An important consideration is that starting with the 2023 Medicare Star Ratings, a greater weight was placed on patient experience measures, increasing their weight from 2 to 4 per measure. As a result, this change reduced the combined weight percentage of medication adherence measures from 10.47%-12.16% from 2015 to 2022 to 8.74% in 2023 and 8.35% in 2024. 2 , 10 , 32 Despite this change, high performance on adherence measures remained positively associated with overall performance, although the magnitude of this association appeared slightly lower in the first 2 years after the change, which may be a result of the change in weighting. However, the upcoming 2026 Star Ratings has lowered the weighting of the patient experience measures back down from a weight of 4 to a weight of 2 per measure. 33 As a result, the combined weight percentage of the medication adherence measures in 2026 will increase to 11.1%. 33
LIMITATIONS
This analysis has several limitations. First, we conducted a cross-sectional analysis of the Medicare Star Ratings performance data and did not consider potential longitudinal effects from year to year. Plans that performed well in prior years may have an advantage in performing well in future years if their members remain in better health. Additionally, plans that perform well on the star ratings and achieve higher-percentage rebates and QBPs earn increased revenue, which they can reinvest back into the health plan to improve performance and patient health outcomes. 9 This can further improve medication adherence for their members in future years. An additional limitation, this analysis did not account for specific demographic or clinical variabilities between health plans that might impact star rating performance.
One aspect not assessed in this analysis is the potential impact of socioeconomic and geographic variance on medication adherence and star rating performance. Research has shown that star ratings have a smaller impact on health plan enrollment for ethnic and racial minorities as well as older adults, resulting in these vulnerable populations enrolling in lower-quality health plans and potentially experiencing worsened health outcomes as a result. 9 , 34 , 35 Additionally, racial and ethnic disparities have been identified and associated with several Medicare Star Rating measures including medication adherence measures, comprehensive medication reviews, and drug-drug interactions. 20 , 36 – 41 Without knowing the breakdown of the population between the health plans in the analysis, it is difficult to determine whether these demographic components contributed to the performance on both the individual medication adherence measures and the overall star rating.
Conclusions
Assessing a decade of the Medicare Star Ratings performance data showed that MAPD plans that performed well on the medication adherence measures had high rates of achieving at least a 4-star overall rating and securing a QBP. This suggests a potential role of medication adherence and health plan performance and financial outcomes. Health plans may see improved performance with initiatives aimed at supporting medication adherence for their beneficiaries. Future research should explore effective interventions and examine how the increased emphasis on patient experience measures in the Medicare Star Rating system can be leveraged to fully understand and enhance the broader implications on health plan ratings and incentives.
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