Based on our work with payers and providers, here are the three most frequently mentioned pain points quality teams face when trying to move their star ratings.
With Medicare revenue under pressure, Medicare Star ratings have evolved from just quality metrics to a primary lever for financial performance. When we talk to quality teams, we hear about new programs and projects implemented to address care quality, however, meaningful improvements to Star rating metrics do not materialize. From our conversations with these teams, it’s clear that stagnant star ratings are not due to a lack of willpower or investments to improve these ratings, but rather a need for improved infrastructure across the industry and a rethinking of how member management is approached. As discussed below, the challenge lies not only in workflows and tools, but also in strategy.
Here are the most common pain points we hear from quality teams when it comes to moving the needle for their star ratings.
Reactive Vs. Proactive Quality Management
Many quality programs remain reactive. Some systems surface medication adherence issues only after non-adherence has already occurred – typically appearing as a late or missed prescription fill. A pharmacy may process a refill, but if the patient never picks it up, the medication is returned to stock 10–14 days later. That reversal is not always reflected immediately in pharmacy claims data. For organizations relying on standard claims feeds, this creates an additional lag. By the time this information gets to the care team, intervention is already delayed, cutting down the time that teams have to address medication adherence barriers.
If too much time passes, the metric becomes unrecoverable for the year. Meaning that even if the patient has 100% adherence for the remainder of the year, they still won’t achieve the Proportion of Days Covered (PDC) of >80%. There are other metrics, like the 7-day window after hospitalizations for transitions of care, medication adherence for Diabetes medications, medication adherence for Hypertension, and medication adherence for Cholesterol that can be unrecoverable. Without tools that allow early visibility, prediction, and prioritization analytics, quality teams miss critical intervention windows to close gaps in time. They need solutions that enable timely, strategic intervention – shifting from reactive recovery to proactive performance management.
Limited Tools for Strategic Prioritization and Population-Level Insights
Some of the current tools adequately identify members that may need assistance or may benefit from additional outreach. However, the majority of these tools don’t segment the data or prioritize patients based on clinical and quality gap urgency, leaving teams to work off static lists. Quality teams are looking for dynamic tools that help them prioritize outreach to high-risk members with urgent care gaps first and reduce the amount of time needed for manual judgement and prioritization. Without this visibility, teams often work on urgent as well as lower-priority cases at the same time and unfortunately many critical interventions worked on too late or never at all.
Beyond individual member identification, quality teams also need population-level visibility. These teams mention that they don’t have enough visibility into emerging population health patterns that indicate where adherence or quality performance is likely to decline based on current trends. They are looking for tools that can analyze care quality and adherence in real time across conditions, medication classes, and member segments, which can help guide their efforts, prioritization, and outreach strategy. These population-level insights also help teams understand which interventions are driving measurable impact and which actions will truly move the needle on specific Star measures.
Fragmented Workflows & Siloed Insights
Healthcare continues to have the problem of fragmented data, leading to isolated care interventions and inefficiencies. Fragmentation prevents teams from addressing quality and cost interventions together, even when they are clinically linked.
Let’s take a look at an example scenario where a patient, “Jon,” is prescribed simvastatin for his cholesterol. However, the patient is late for his refill, so the quality team reaches out to address medication non-adherence. The patient mentions that he has a hard time remembering to take his simvastatin before bed like his provider instructed, especially since his other medications are taken earlier in the day. The pharmacist mentions that there are other statin medications that can be taken at any time of the day. The pharmacist offers to reach out to his provider about switching to a statin like atorvastatin, that can be taken at the same time as his other medications.
At the same time, a cost of care initiative is reaching out to patients who have 30-day fills of statin medications to transition them to 90-day fills. The team reaches out to Jon to see if he is interested in getting his simvastatin as 90 day fills and doesn’t know that earlier this week, he spoke with another team and had plans to change their simvastatin to atorvastatin, since they use different systems. Jon is confused why he’s getting so many calls about his cholesterol medication, but in the end tells the cost of care team that he is open to getting a 90 day supply instead of a 30 day supply. Now his provider receives two messages from the health plan. One team mentions that Jon would like to switch to atorvastatin , while the other requests a 90-day fill of simvastatin.
When teams work across disconnected systems or tools, they often lack visibility into the full clinical picture and the broader intervention opportunity for each patient. The result can include inefficiencies, member confusion, potential medication risks, and added friction for providers, ultimately making it more difficult to improve both adherence and cost-reduction outcomes.
With an integrated, comprehensive platform like MDI, clinical and quality opportunities can be surfaced at the same time and addressed through a coordinated intervention. This enables a clearer, more streamlined strategy, helping teams reduce unnecessary outreach, support providers more effectively, and improve both quality performance and cost-of-care efforts.
If this sounds familiar to you and you’re looking for new tools that can help you improve your STAR ratings, reach out: info@mdihealth.com
Check out our Quality Improvement Solution and Cost of Care Reduction Solution to learn more.