2022 CMS Star Ratings, Impact, and Implications

The 2022 Star Ratings represent a measurement year that will be an outlier. Star Ratings were the highest they have ever been, yet churn is the largest health plans have experienced. CMS made a variety of decisions to help avert the COVID impact, including:

1. Delaying implementation of the guardrails for one year (enabling cutpoint changes by more than 5% if national performance declined)
2. Expanding the hold harmless provision for improvement measures to prevent an overall rating decrease
3. Temporarily removing the 3x weighted HOS measures due to the undermining effects from COVID

The HOS removal and Member Experience weight changes have been fundamental in shifting the average Star Rating. As described in our article published August 11, 2021, before the 2022 changes, Member Experience measures accounted for 37% of Star Ratings. The removal of the above measures boosted the importance, with Member Experience measures now accounting for 43% of all measures. In 2023, with the Star Rating removals, temporary suspensions, and proposed additions, Member Experience measures will account for 60% of the ratings.

Key Observations

​​Both the share of 4.0+ rated plans by enrollment and count increased from 2021. Ninety percent of membership is enrolled in a 4.0+ rated plan, representing 68% of contracts by count. This is an unprecedented increase over the 77% of members who belonged to a 4.0 Star plan last year.

In addition, 26.6% of members are enrolled in a 2022 5-Star plan, which is a 2.9x increase from 2021 ratings (9.15% of members were enrolled in 5-Star Plans in the 2021 ratings). This is key because these plans are allowed to market year round compared to others that are permitted to do so only during the open enrollment period (October 15 to December 7). This relates specifically to United, Humana, Kaiser, and Centene, which have outsized market share and all achieved a 5-Star Rating in 2022.

Over time, this could create an uncompetitive market for smaller regional plans already losing 65-70% of all new MA members to the largest health plans. For this reason, it’s more important than ever for these regional plans to drive toward a 5-Star Rating to remain competitive.

Year over Year Change	Percent of Plans	Count of Plans
>=+ 1.0	8.2%	32
+0.5	53.5%	209
0	37.6%	147
=0.5	0.8%	3
>= -1.0	0.0%	0

391 contracts received a Star Rating in both 2022 and 2021. The movements in ratings from 2021 to 2022 are summarized below:

In addition to the above, the following presents the percent of plans performing in 2021 against 2022. For example, 1.8% of 2021 3-Star plans fell back to a 2.5-Star Rating in 2022, 39.1% of 4.5-Star plans maintained a 4.5-Star Rating in 2022, and 54.7% of 2021 3.5-Star plans improved to a 4-Star Rating in 2022. The largest change was 2.5-Star plans moving to 3 Stars.

Overall Star changes from 2021 to 2022 for the 391 plans with ratings in both years are summarized below.

More than one-third (37.65%) of plan contracts maintained the same Star Rating year over year. It’s less common to move by more than 0.5 in either direction (8.2% of contracts). Compared to 2021, plans were much more likely to improve or maintain their Star Rating in 2021.

• Improved: 61.6% of plans vs. 16.4% of plans in 2021 (+45.2%)
• Maintained: 37.6% of plans vs. 62.0% of plans in 2021 (-24.4%)
• Fell back: 0.8% of plans vs. 21.5% of plans in 2021 (-20.7%)

2022 Disaster Adjustments

The extreme and uncontrollable circumstances policy for the 2022 Star Ratings noted that if a measure-level Star Rating was lower in the current year, the measure-level Star Rating would revert to the rating from the prior year. The following are contracts in the 2022 Star Ratings that reverted to the 2021 Star Ratings for eligible measures.

CAHPS and Member Experience

The Patients’ Experience and Member Complaints (“Member Experience”) consideration was a critical influencer for the 2022 Star Ratings and will only continue to be so going forward with the weight change from 2 to 4. The CAHPS performance is based on the higher of the 2021 or 2022 Star Rating for each CAHPS measure given. (Note: Plans were allowed to rely on their 2020 Star Rating for the 2021 year due to COVID, so those that rely on 2021 ratings may be defaulting back to the 2020 Star Ratings).

Member Experience with Plan (CAHPS) Measures

The following are measures captured through the CAHPS survey:

Measure Name	Weighting Category	Source	2021 weight	2022 weight	2023 weight
Getting Needed Care	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4
Getting Appointments and Care Quickly	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4
Customer Service	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4
Rating of Healthcare Quality	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4
Rating of Health Plan	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4
Care Coordination	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4
Rating of Drug Plan	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4
Getting Needed Prescription Drugs	Patients’ Experience and Complaints Measure	CAHPS	1.5	2	4

CAHPS measures in the category “Patients Experience and Complaints” have a 2.0 measure weight for 2022 and make up approximately 20.6% of an overall MA-PD Score (approximately 19.7% for MA-PD SNP). Performance in these measures is highly influential in the overall rating of a contract:

• 94.4% of plans achieving an Overall Rating of 4.0 Stars or higher achieved at least a 4.0 average rating in Domain 3.
• 89.4% of plans achieving an Overall Rating of 4.0 Stars or higher achieved at least a 3.5 average rating in Domain 3.

In addition to the CAHPS measures, others also contribute to the overall Member Experience rating:

Measure Name	Weighting Category	Source	2021 weight	2022 weight	2023 weight
Complaints about the Health Plan	Patients’ Experience and Complaints Measure	CTM	1.5	2	4
Members Choosing to Leave Plan	Patients’ Experience and Complaints Measure	MBDSS	2	2	4
Plan Makes Timely Decisions about Appeals	Measures Capturing Access	IRE	2	2	4
Reviewing Appeals Decisions	Measures Capturing Access	IRE	2	2	4
Call Center – Foreign Language Interpreter and TTY Availability	Measures Capturing Access	Call Center	2	2	4
Complaints about the Drug Plan	Patients’ Experience and Complaints Measure	CTM	1.5	2	4
Members Choosing to Leave the Plan	Patients’ Experience and Complaints Measure	MBDSS	1.5	2	4

For the 2022 Star Ratings, 94.8% of plans achieving an Overall Rating of 4.0 Stars or higher achieved at least a 4.0 average rating in Patients’ Experience and Complaints Measures. 87.8% of plans achieving an Overall Rating of 4.0 Stars or higher achieved at least a 3.5 average rating in Patients’ Experience and Complaints Measures.

A previous Icario article analyzed the impact of the overall weight changes. For 2022, we analyzed all Member Experience Star Ratings (in addition to CAHPS), to understand the impact of moving from 1.5 to 2 Stars. We found that changing the weighting from 1.5 to 2.0 changes the overall rating from 3.58 to 3.63.

2022 MA Stars Ratings: Voluntary Churn

For 2022, voluntary churn increased from 2021 (up 0.3% for the average). This reflects an 8-year high for voluntary churn across MA.

It’s not surprising that plans with lower Star Ratings showed a much higher churn rate. For example, in 2022, plans with 2.5 Stars saw a 17.3% average churn rate; plans with 5 Stars experienced only a 4.1% churn rate.

In looking at the category “Members Choosing to Leave Plan,” the churn rate among the upper 75th percentile of contracts is 19%, meaning 25% of plans have a churn rate of 19% or higher. However, plans in the upper 25th percentile churned at a rate of only 6.0%.

Recap of Significant Changes to Star Ratings

There have been significant changes to the 2022 Star Ratings. There are additional changes anticipated for 2023 reflected below.

2022 Changes

Removed Measures	Adult BMI Assessment Appeals Auto-forward Appeal Upheld
Temporarily Removed	Improving or Maintaining Physical Health Improving or Maintaining Mental Health Controlling High Blood Pressure Plan All-Cause Readmissions Care of Older Adults – Functional Status Assessment

2023 Anticipated Changes

New/Returning Measures	Controlling High Blood Pressure (was set to return in 2022
Removed Measures	Rheumatoid Arthritis Management
Temporarily Removed	Improving or Maintaining Physical Health Improving or Maintaining Mental Health Plan All-Cause Readmissions (was set to return in 2023) Care of Older Adults – Functional Status Assessment
Changing Weights	Statin Use in Persons with Diabetes Decreases to 1x (also reclassified as a process measure from intermediate outcome measure) Most Member Experience Measures Increase from 2x to 4x (since 2022)

Implications for 2022 Star Ratings

This is a historical high for the number of people enrolled in plans with 4-Stars. With the ability to leverage 2020 ratings established by the Public Health Emergency where the plan would otherwise experience poorer performance – the ratings have been overinflated in such a way that we should expect to see a significant drop in performance with regression toward the mean in 2023. Plans will need to continue to invest heavily to keep their ratings high now that a larger number may experience a fall from grace.

In addition, with churn rates also being at an all-time high, plans cannot afford to underinvest in Member Experience. To understand the magnitude of the impact, a plan that has 200,000 members with a capitation payment of $840 per member per month and a 13% churn rate will lose $262M in reimbursement. Reducing plan churn by 5% (to a churn rate of 8%) will increase revenue by $100M.

Likewise, when plans receive a higher rating, they have a corresponding increase in their QBP. A greater portion of QBP can go toward supplemental benefits to create a more comprehensive package as well as a competitive advantage, especially as more plans are easily able to offer $0 premium options. These $0 premium plans combined with a robust set of supplemental benefits create the most robust offering likely to attract additional membership. 

Aetna, Cigna, Humana, and United already announced updates to their benefit plans with additional supplemental benefits for their populations, many of which address social determinants of health (SDoH).

The $6 billion that CMS is spending on QBPs will force a reckoning that will result in lower ratings. This path of improvement is unsustainable, and a drop is inevitable. This will largely impact those teetering on a lower rating where a change will force a downward rating correction and a substantial decrease in revenues year over year.

Worth noting is CMS’ anticipated reinclusion of the Tukey outlier deletion for the 2022 measurement year. Through this mechanism, the highest and lowest rate plans are removed to calculate cutpoints. The impact of this change will prevent outliers from having an outsized effect on Star Ratings, but increasing cut points will also change the distribution of plans receiving 4 Stars and above. 

It will also cause poorer-performing plans to continue to experience a decline in ratings as more outliers tend to fall at the low end of the distribution, creating a downward shift for overall Star Ratings. Some report the Tukey outlier deletion will bring balance to the estimated increase in Star Ratings created by the Member Experience Star Rating weights. The goal of the Tukey outlier methodology is to ultimately save CMS millions of dollars in QBPs by decreasing the propensity for awarding higher Star Ratings. 

This year’s Star Ratings represent a systematic shift with seismic effects on future Star Rating years. At this point, 2022 is the last year plans will have a grace period afforded by COVID. This combined with the levers that will create a downward adjustment foretell a decrease in Star Ratings, and plans will need to work quickly to address future impacts.

Improving Member Experience ratings can help offset the Tukey outlier effect and other mechanisms designed to save money through decreased QBPs. Member Experience will be one of the most critical drivers of Star Ratings. In this environment, there is no such thing as over investment to drive Member Experience scores higher to help maximize these Star Ratings.

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