Industry Voices—Why MA star ratings should account for the social determinants of health

Star ratings score rankings
CMS should better consider the social determinants of health in its Medicare Advantage star ratings, writes Clover Health's Erica Pham. (Getty/Oko_SwanOmurphy)

Does a low-income senior in rural Texas have the same healthcare access as a high-income senior in Charleston's Historic District?

The answer to that is clear: no.

Should social determinants of health, including geography and socioeconomic status, be considered an important factor for measuring the quality of care provided to Medicare Advantage beneficiaries by the Centers for Medicare & Medicaid Services (CMS)?

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The answer to that is also clear: yes.

No matter your demographics, achieving and maintaining good health as you age can be difficult. And it can be a challenging task to select the best healthcare plan to satisfy your complex health needs. To this end, the Medicare Star Ratings System was developed by CMS to help older and disabled Americans choose the health plan best for them by developing clear comparisons and a quality standard for Medicare Advantage plans.

However, despite the best of intentions, the Star Ratings ranking system penalizes plans serving disadvantaged populations. The consequence, according to researchers from Brown University, is that the system does not fully account for socioeconomic factors like education level, income, and neighborhood, and therefore, misstates the quality of plans serving these often minority and rural communities.

RELATED: Kaiser leads the way in average Medicare Advantage star ratings for 2019

Failing to account for these socioeconomic factors distorts star ratings results and perpetuates a cycle of underfunding and lack of choice for the communities most in need. Because CMS ties funding and the timing of plan advertising, as well as plan supplemental benefits, to a plan's score, insurers face strong disincentives to serve lower-income or minority communities.

CMS has even acknowledged that the Star Ratings and quality methodology does not fully address or incorporate socioeconomic status factors, and yet it has not gone far enough to fix the situation.

Thus, while originally unintentional, the dismissal of necessary foundational fixes to the star ratings system has emerged as a regulatory barrier that deters Medicare Advantage companies from serving disadvantaged communities. This barrier deprives those historically underprivileged communities—often rural areas and communities with higher percentages of African Americans or Latinos—of the same variety of plan choices and supplemental benefits offered to more affluent or well-resourced communities.

Medicare Advantage plans like Clover, which seek to provide coverage in underserved rural and urban counties, have a disproportionately high customer base with chronic diseases. By failing to adequately account for the ways in which caring for higher-risk populations skews star ratings lower, CMS policies punish plans like Clover and ultimately, their members. Lower star ratings means reduced reimbursement from CMS and therefore fewer resources to invest in health plan benefits for patients.

RELATED: Clover Health says network adequacy rules, provider consolidation inhibit entry into new markets

This harmful cycle is preventing forward progress in improving the health of aging Americans.

CMS should take action and accelerate their approach to addressing the socioeconomic inequality that affects health outcomes in many communities that Clover serves. Our goal at Clover is to improve the health of America's seniors. Even if it hurts our bottom-line, we will provide our health plans to the communities that need access to quality healthcare the most.

Fortunately, CMS reevaluates star ratings every year and has the chance to design a more balanced system that accurately reflects a plan's performance, no matter the population it serves. With healthcare as the number one issue for voters, there's no time to wait; these health disparities need to be addressed now.

When CMS makes this important change, including socioeconomic and geographic factors in its MA star ratings, it will improve health care access for Medicare beneficiaries across America.

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