Medicare Advantage plan rankings may not accurately reflect the quality of care given to plan enrollees, according to a recent study by Brown University researchers. The study, published in Health Affairs,  found that Medicare Advantage plans suffer in federal quality rankings when they serve a higher number of non-white, poor and rural Americans.


When researchers adjusted the performance rankings for race, neighborhood poverty level, and other social risk factors, plans serving the highest proportions of disadvantaged populations scored higher in the rankings, according to the Health Affairs study.

“Policymakers have focused a lot of attention on measuring quality and rewarding better performance among health plans and providers,” Amal Trivedi, an associate professor of health services, policy, and practice at Brown and the study’s senior author, said in a study announcement. “But in order for these quality assessments to be accurate, they need to take into account the characteristics of the populations that are served.”

How CMS measures quality

The rankings by the Centers for Medicare & Medicaid Services measure a plan’s quality by looking at how well health care providers perform in 30 categories, including customer service, efficiency in processing claims and appeals, disease screening rates, and patients’ body mass indexes. The Brown study adjusted for socioeconomic disadvantage in three of those categories—blood pressure control, cholesterol control, and diabetes control—and found that many lower-ranked plans moved substantially higher in the rankings.

The study showed that 20.3%, 19.5%, and 11.4% of Medicare Advantage plans improved by one or more quintiles in rank on the diabetes, cholesterol, and blood pressure measures, respectively.

Researchers chose those categories because previous studies found that disadvantaged populations disproportionately suffer from uncontrolled high blood pressure, high cholesterol levels, and diabetes.

CMS currently accounts two risk factors in the ranking: dual eligibility, which indicates that someone qualifies for both Medicare and Medicaid, and disability.

“The adjustments CMS uses do not fully account for true measures of socioeconomic status, such as income level, education, and employment,” said lead study author Shayla Durfey in the announcement. “These factors have been shown to play a huge role in a person’s lifetime health.”

The impact of CMS rankings

Accurate quality rankings are important because CMS gives plans an incentive to compete against each other, according to Trivedi. For example, a plan with a five-star ranking receives a sizeable payment bump. But a plan that has a one-star rating is penalized: All of its enrollees receive letters encouraging them to switch to better plans.

That gives plans little incentive to serve socioeconomically disadvantaged enrollees.

“Medicare plans can’t deny coverage to anyone with a pre-existing condition, but they can operate in areas that are more affluent or have healthier, less disadvantaged populations, leaving poor and rural populations with fewer and fewer options,” Trivedi said.

Furthermore, a new brief by the Kaiser Family Foundation, notes that disparities in health and health care also limits overall improvements in quality of care and health for the broader population and result in unnecessary costs.  Indeed, a recent analysis by Altarum found that disparities lead to  $93 billion in excess medical care costs and $42 billion in lost productivity each year. These disparities are attributed to what is commonly referred to as “social determinants of health,” which are the underlying drivers that erode the Medicare Stars performance of Medicare Advantage plans that enroll disadvantaged populations. 

Interested in learning more? Check out our upcoming live events relevant to this topic including The 8th Annual HEDIS & Quality Improvement Summit, The 9th Annual RISE Star Ratings Master Class, The 12th Annual Medicare Marketing & Sales Summit & The 2nd Annual RISE Symposium on Partnering to Address Social Determinants of Health.