The Medicare Advantage STAR rating game has new rules, and they're shaking up the status quo. Gone is the familiar Reward Factor that many plans relied on to boost their ratings. In its place? The Health Equity Index (HEI) reward – a game-changing shift that puts your hardest-to-reach members center stage. If your plan has been counting on across-the-board quality improvements to secure that crucial 4+ star rating, it's time for a strategy reset. Moving forward, success hinges on how well you serve your most vulnerable populations.
Here are four essential things your health plan needs to know about this pivotal transformation – and how to succeed.
- The Focus Has Shifted to High-Risk Populations: Unlike the previous reward factor that considered overall membership performance, the new HEI reward specifically targets three high-risk populations: Dual-Eligible (DE), Low-Income Subsidized (LIS), and disabled members. Health plans that have historically relied on broad-based quality improvements to achieve their Star ratings must now demonstrate excellence in serving these specific populations to maintain their 4+ Star rating and associated quality bonus payments.
- Social Risk Factors present complex challenges – and more complex patients: A recent ActualMeds survey revealed the complexity of addressing these populations. Consider these statistics and how these social risk factors create multiple barriers to care that plans must actively address:
- 58% of DE/LIS members take more than 4 medications regularly.
- 24% have stopped taking medications due to cost concerns.
- 19% have had to choose between buying prescriptions or paying for important things like food or a place to live.
- 28% report feelings of loneliness or social isolation.
- 30% have discontinued medications due to side effects.
- Traditional engagement methods will not be sufficient: The days of relying solely on automated messages and calls are over. The complexity of serving DE, LIS, and disabled populations requires a more sophisticated approach. Members often face multiple challenges simultaneously - from transportation barriers to language difficulties, from complex medication regimens to economic constraints. Success under the new HEI reward system demands comprehensive strategies that address these interconnected challenges.
- Medication Adherence must be the critical focus area: Triple-weighted medication adherence measures significantly impact overall Star ratings and are particularly challenging for high-risk populations. The connection between medication adherence and health outcomes is clear - improved adherence leads to reduced hospital admissions and readmissions for chronic diseases. Plans need to implement scalable, tech-enabled solutions that combine data-driven processes with human interaction to effectively manage medication adherence among these populations.
Moving Forward with the Right Partner
To succeed under the new HEI reward system, health plans must reimagine their approach to quality improvement. This means developing targeted strategies for DE, LIS, and disabled members that address both clinical needs and social risk factors. Plans must consider partnering with organizations that have demonstrated success in managing these populations and can provide the technological infrastructure needed to scale these efforts effectively.
The reality is that the shift to the HEI reward system represents both a challenge and an opportunity. It may require significant operational changes, but it also provides a clear path for health plans to align their quality improvement efforts with CMS's broader goals of advancing health equity and improving outcomes for their highest-risk members.
ActualMeds believes deeply in health equity and has long been the leader in this space. Among MA members for which ActualMeds’ provides end-to-end Stars Adherence Management, approximately 2/3 are LIS/DE and over 1/3 are Disabled status.
Here’s the breakdown.
- 71% LIS
- 62% Dual Eligible
- 37% Disability
We can help and have proven results to share. To learn more about starting 2025 with a STARS strategy that enables success with the HEI reward through better medication adherence, visit https://www.actualmeds.com/solutions#adherence-stars.