The views expressed by contributors are their own and not the view of The Hill

Medicare star ratings perpetuate health disparities

Getty Images

Visit a hospital in rural Alabama and one in suburban Virginia, and you’ll likely have two different experiences given differing populations and resource levels. This is one of the problems of our healthcare system: the great promise that all Americans have equal opportunity to succeed doesn’t translate when it comes to our health.

For older Americans, Medicare Star Ratings System is supposed to help. Established by the Centers for Medicare and Medicaid Services (CMS) in 2007, the system is intended to reflect a plan’s quality and performance and, in turn, help consumers assess and compare Medicare Advantage plans. The problem is that the Star Ratings system does not fully account for socioeconomic factors that distort results and may perpetuate a system of underfunding for communities that need it most.

{mosads}In fact, researchers from Brown University found that Medicare Advantage rankings penalize plans serving disadvantaged populations. By accounting for just a few risk factors — dual eligibility with Medicaid, low income subsidy, and disability — the ratings system overlooks numerous other factors like language proficiency, education, and employment that give a more accurate reflection of a community’s baseline health status.

The lower ratings aren’t just a problem for an insurer’s reputation. Because CMS ties funding and the timing of plan advertising to their score, insurers face strong disincentives to serve lower-income or minority communities. Thus, while unintentional, CMS’ ranking system has emerged as a regulatory barrier that deters Medicare Advantage companies from serving disadvantaged communities and deprives those communities of the variety of plan choices and supplemental benefits offered to more affluent communities.

The current Star Ratings structure seeks to promote a universal quality standard, but instead unfortunately perpetuates disparities that have existed for decades. It turns a blind eye to the cultural practices, social norms and historic lack of healthcare access that affect health status in certain communities.  

Here is a very real example: a 67 year-old Latina from New Jersey who is a Clover Health member refuses to use injectable medications to control her diabetes. She is afraid of needles, and the out-of-pocket costs for these medications are barely affordable. She also is predisposed to believe problems are inevitable as many family members have had diabetes complications requiring renal dialysis and/or lower extremity amputations. Most of these complications are due to poor healthcare access and diabetes control prior to Medicare coverage, but that is often overlooked.

Because of this systematic disparity, Medicare Advantage plans like Clover, which seek to provide coverage in underserved rural and urban counties, have a disproportionately high customer base with greater chronic disease “debt,” an output that factors in both disease prevalence and management. By failing to adequately account for the ways in which caring for a larger percentage of these higher risk populations skews Star Ratings lower, CMS’ policies punish these plans and ultimately their patients. Lower Star Ratings means reduced reimbursement from CMS and fewer resources to invest in health plan benefits.

This harmful cycle is preventing progress in healthcare for older Americans. Fortunately, CMS reevaluates Star Ratings every year and has the chance to design a fairer system that accurately reflects a plan’s performance, no matter the population it serves. To CMS’ credit, they recognize the need for improvement and are open to continually re-evaluating measurement adjustments to make Medicare Advantage a universal option for those eligible.

The status quo should not be the enemy of common-sense solutions. With healthcare as the number one issue for voters in 2018, now, more than ever, is the time to address these health disparities.

It’s a simple ask with meaningful results: include socioeconomic and geographic factors in the Star Ratings clinical measure methodology. By making this fix, CMS improves access to the increasingly popular Medicare Advantage choices and enhances care quality for all beneficiaries.

Dr. Sophia Chang, a physician, is the chief clinical informatics officer for Clover Health and holds a master’s degree in Public Health.


Copyright 2023 Nexstar Media Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

More Healthcare News

See All
See all Hill.TV See all Video

Most Popular

Load more


See all Video