7 Data-Driven Strategies to Improve Star Ratings

The Medicare Advantage (Medicare Part C) and Medicare Part D Star Ratings, published annually by the Centers for Medicare & Medicaid Services (CMS), are a primary resource for consumers evaluating and comparing potential health plans. They also play a central role in shaping financial incentives and overall profitability for health plans. As such, knowing how to align with and improve star ratings is crucial for payers to stay competitive in today’s marketplace.

The financial implications of changes to an organization’s Star Ratings can’t be understated—CVS Health, for example, estimated a staggering $1 billion decline in operating income in 2024 when its Aetna National PPO plan received a one-star rating decrease in 2023 (from 4.5 to 3.5 stars) and thus became ineligible for bonus payouts.

Other entities are experiencing similar challenges. Average Star Ratings took a dip across the board last year, from 4.14 in 2023 to 4.04 in 2024, and only 31 plans earned five stars (compared to 57 in 2023 and 74 in 2022). Some health plans suggest this drop is due to more intense evaluations post-pandemic, but internal challenges undoubtedly contribute as well.

In particular, the need for more effective healthcare data management is becoming imperative. Health plans and providers now process more data from more sources than ever before, requiring a strategy to streamline its collection and management. Concurrently, expectations from CMS and other governing bodies around data quality and reporting accuracy are intensifying.

In order to improve Star Ratings, drive profitability, maintain a strong market position, and ultimately serve customers well, health plans must implement data management strategies to meet new healthcare data requirements and standards.

Key Takeaways:

• The CMS Star Ratings system uses a diverse set of data sources to determine and award ratings.
• Health plans and providers need a robust data management strategy to improve Star Ratings and stay aligned with evolving standards.
• Key strategies such as high interoperability, master data management, data analytics, quality assurance protocols, and clear reporting and documentation enhance Star Ratings potential.
• Gaine’s CoperorTM Health Data Management Platform supports and extends data capabilities so that organizations can meet industry standards and optimize performance.
  
  

Data Reporting and Star Ratings

Payer and provider data reporting capabilities are a huge determinant of their potential Star Ratings. The system uses 40 measures and based on a diverse set of data sources to analyze and award ratings, including but not limited to:

• Results from Other Evaluation Initiatives: Programs such as the Health Effectiveness Data and Information Set (HEDIS), the Health Outcomes Survey (HOS), and the Consumer Assessment of Healthcare Providers and Systems (CAHPS)
• Clinical Outcomes Data from Providers: Includes metrics like hospital readmission rates, disease management progress, and preventative screening rates
• Customer Service Metrics: Includes metrics around call center performance, responsiveness and availability, and timeliness in handling enrollments and appeals
• Health Plan Administrative Data: Covers the accuracy and completeness of data submissions to CMS, proper coding, and claims processing accuracy
• Pharmacy Data: Includes data around medication error rates, drug safety, and accuracy of pharmacy benefit management
• Patient Experience Data: Results from surveys distributed to patients from all touchpoints, including providers, health plans, and pharmacies

This list isn’t exhaustive, but demonstrates the breadth and diversity of data used to develop and award Star Ratings. Even small inaccuracies in data analysis and reporting can result in a lower star rating with serious financial implications.

Boston Consulting Group reported that moving up just half a star rating—from 3.5 to 4 stars—leads to a $400 increase in financial incentives per member, or $60 million in revenue for a 150,000-member plan.

In other words: Inaccurate data that doesn’t adequately or fully reflect the quality of your service and performance could result in significant, direct financial losses—not to mention residual losses that may come later due to lower enrollment.

Further, Star Ratings (and other health plan quality and performance evaluation initiatives) evolve and change over time, meaning your data strategy must be intentionally designed to align with updated and new requirements as they’re introduced.

Fortunately, these risks and challenges can be remediated with an optimized data management strategy and the right tools and processes in place to support it.

7 Data Management Strategies to Improve Star Ratings

A holistic data management strategy is essential for organizations aiming to maintain and improve Star Ratings. By putting an end-to-end focus on how data is collected, integrated, and utilized, organizations can significantly impact their performance metrics and thus directly influence their ratings. Below are 7 strategic approaches to optimize data management for greater ratings success:

1. Streamline Data Collection Across Sources

Ensure all relevant data is being collected and managed by streamlining your data collection processes. This includes (but is not limited to) electronic health records (EHRs), patient surveys from both providers and payers, pharmacy records, healthcare ERP data, and more. Standardizing data collection ensures completeness and uniformity, making it easier to analyze and report on key metrics.

2. Maximize Data Integration and System Interoperability

Healthcare ecosystems can be vast and complex. Data flow must be seamless in order for health plans to have complete, up-to-date, and accurate insights about quality and performance. Align systems with new requirements (like HL7 FHIR) for a unified view of patient information across the patient journey.

Organizations must also prioritize payer-provider collaboration to enable effective patient engagement while also supporting overarching management of data sharing and patient outreach.

3. Implement Master Data Management (MDM)

Master data management (MDM) is fast becoming a table-stakes capability for health plans who want to meet Star Ratings standards, optimize operations and care quality, and maintain regulatory compliance. Deploy an MDM solution to maintain a single, standardized, and accurate view of critical data across your organization and ecosystem.

4. Leverage Data Analytics and Business Intelligence

Integrating advanced data analytics and business intelligence is essential for translating healthcare data into actionable insights. Analytics can help payers identify care gaps, optimize resource allocation, and be more proactive in pinpointing and addressing areas that need focus to help improve Star Ratings.

5. Optimize Reporting and Documentation

Reporting and documentation is critical for maintaining both a historical understanding of health plan quality and performance, and for remaining compliant with regulatory requirements. Ensure (and automate when possible) documentation processes, aiming for clear accountability and traceability to support data veracity in Star Ratings submissions.

6. Implement Processes for Quality Assurance

Maintaining exceptional data quality is essential to accurate and reliable Star Ratings reporting. Establish rigorous data quality assurance protocols such as routine data audits, validation checks, error tracking, and reconciliation procedures. Implement corrective measures to address data discrepancies and ensure that data used for Star Ratings calculations meets quality standards.

7. Achieve Real-Time Data Processes

Enhancing real-time data processing capabilities is essential for health plans aiming to improve their Star Ratings through ongoing care quality and operational optimization. By implementing systems to provide instant data analysis, health plans and providers can quickly identify and address care gaps, discrepancies in treatment, internal inefficiencies, and other emergent issues.

This immediate responsiveness helps prevent potential declines in Star Ratings and supports proactive interventions, ensuring continuous alignment with the latest quality standards.

Looking Ahead

CMS will continue to evolve its Star Ratings system in 2025 and beyond, including some confirmed planned changes like updates to hold harmless provisions, a “universal foundation” approach to quality measures across care programs, and several proposed rule and provision updates or removals.

A comprehensive data management strategy will allow your organization to stay aligned with these changes as they come, while maintaining real-time and easy access to the data you need to continually assess your performance.

Gaine’s CoperorTM Health Data Management Platform (HDMP) is a powerful solution built to revolutionize data interoperability across healthcare ecosystems. CoperorTM HDMP supports and extends data capabilities to empower healthcare organizations to meet industry interoperability standards such as HL7 FHIR and leverage data strategically to drive improvements in operational efficiency and quality of care.

Maximize your organization’s Star Ratings potential with Gaine. Learn more here about CoperorTM HDMP and how to get started.