From its inception, Medicare Advantage (MA), a program in which private health insurers contract with the Medicare program to provide coverage on a capitated basis, has faced significant criticism that insurers were engaging in cherry picking, a form of favorable selection designed to enroll healthier individuals with fewer health care costs into their plans while encouraging other individuals with higher health care costs to remain in traditional Medicare.1 In 2007, following earlier efforts to address favorable selection,1 the Centers for Medicare & Medicaid Services (CMS) introduced star ratings to guide beneficiaries’ enrollment decisions by providing them with information about MA plan performance while incentivizing quality by rewarding highly rated MA plans with bonus payments beginning in 2012.2 There is growing evidence that Medicare beneficiaries are more likely to select and remain enrolled in MA plans with higher star ratings.3 Yet, as Gupta et al4 highlight in their study, structural inequities in access to highly rated MA plans are a growing cause for concern.
In their cross-sectional study using 2023 CMS data on MA plans (including service area and star rating) in 3075 US counties merged with 2020 county-level data on social vulnerability from the Centers for Disease Control and Prevention’s Social Vulnerability Index, Gupta et al4 found evidence of an inverse association between the social vulnerability of a county and the star ratings of MA plans available to Medicare beneficiaries living there.4 They found that the most socially vulnerable counties had a higher number of low-rated plans (less than 3.5 of 5.0 stars), a lower number of the highest-rated plans (4.5 or 5.0 stars), and a 0.24-point lower mean star rating across all plans in the county compared with the least socially vulnerable counties. Moreover, the mean star rating decreased monotonically across quintiles of counties as they became increasingly socially vulnerable
Wright, B. (2024). Structural inequities in Medicare Advantage—A growing cause for concern. JAMA Network Open, 7(7), e2424096. https://doi.org/10.1001/jamanetworkopen.2024.24096
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
