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The 2026 STAR Ratings Are Here: Time to Stop the Bleeding

ActualMeds Team
October 01, 2024 3 min read

 

The new STAR ratings just dropped and no surprise, adherence rates go up. Yet, STARs scores go down.

Here's the painful irony: Adherence quality is improving, but Medicare keeps moving the goal posts. Health plans are getting better at adherence showing higher rates, yet their adherence Star ratings continue to fall. In the current reward structure, even a single percentage point gain in these triple-weighted measures is worth millions to plans

Regardless of where you plan is tracking to this year, if you’re unsure it will reach that next Star level, perhaps it is time to add a different approach to your strategy.

Why Traditional Approaches Keep Failing

Robocalls go unanswered. Mass text messages get ignored. Broad outreach campaigns burn resources while producing minimal results.

The problem? These approaches lack precision.

Medication adherence isn't a "one and done" measure like cancer screenings. You can't simply check a box and move on. Adherence requires year-round monitoring. It demands continual attention to ensure prescription refills are properly timed. Most health plans are still relying on their legacy solutions. They're using outdated technology and analytics that can't keep pace with rising cut points and increasingly complex member populations.

What High Performers Do Differently

Health plans achieving adherence rates 2-3% above Medicare averages share four common strategies:

  1. Precision Targeting and Smart Timing: They know it’s time to stop casting wide nets and start hitting bullseyes. Using real-time claims analysis to identify members at risk of failing adherence measures and applying priority algorithms to analyze daily data can pinpoint the right patient at the right time. Historical data only tells part of the story. You need processes that contact members at optimal moments in their care journey.
  2. Pharmacist-Led Care Teams: Human connection still drives better results in our digital age. By enabling pharmacist-led teams to create real relationships with members, not just robocall touchpoints, even the hardest to reach patients can be adherent. Your care team should understand both pharmacy and medical channels. They need to be ready to address the unexpected. Go beyond telling members what to do. Help them complete the process.
  3. Advanced Real-Time Analytics: Simply looking at pass or fail criteria from previous years won't cut it anymore and hasn’t for years. Smart plans are using data-driven strategies to build dynamic models that update frequently based on the latest data. After all, pharmacy is a 24/7 business. As adherence rates and cut points increase, small pockets of opportunity become critical differentiators that can be addressed via large provider groups, pharmacies, and value-based care partners.
  4. Local Ecosystem Coordination: No single entity can solve adherence challenges alone. It’s vital to establish clear communication channels with all partners and create data-sharing protocols that support 24/7 pharmacy operations. Data interoperability facilitates seamless coordination between health plans, providers, pharmacies, and strategic partners and relationships matter.

Meet Your Two-Track Action Plan

No matter where your plan stands today, it’s urgent to take action for the remainder of this calendar year and to prepare for a strong start to 2026.

Track 1: Stop the Bleeding Now

We're already deep into the 2025 measurement year. The window to make a meaningful difference is measured in weeks, not months.

You need immediate action with proven experts who can analyze your data quickly. Deploy automated, data-driven processes to increase engagement probability. Implement scalable, personalized outreach for challenging, high-risk members who require human interaction. Stopping the bleeding will keep you from falling deeper into trouble zones that are even more difficult to come back from in the new year.

Partner with specialists who have extensive experience in medication adherence. The right partner can identify gaps in your adherence measures and begin targeted outreach to the members who matter most for the remainder of the measurement period.

Track 2: Prepare for 2026

The 2026 requirements will be even more stringent. CMS is implementing risk-adjusted measures specifically focused on Social Determinants of Health. The new Excellent Health Outcomes For All reward ties STAR ratings exclusively to performance among Dual-Eligible, Low-Income Subsidy, and disabled populations.

These are the hardest members to reach. What worked last year may not work next year.

Start building your foundation now:

  • Define your target population with social and clinical risk factors
  • Configure your data infrastructure for interoperability
  • Leverage data-driven algorithms to prioritize daily outreach
  • Build care teams proficient in both pharmacy and medical channels
  • Enable comprehensive support that addresses transportation, appointments, and billing problems

The Bottom Line

In the world of STAR ratings, everyday counts. Technology and data are essential, but people are the ultimate variable. Plan members are human, and humans are unpredictable.

After all, you can't control CMS raising cut points. But you can control how you respond.

Health plans using precision targeting along with pharmacist-led care teams and advanced analytics are achieving measurable results. They're seeing adherence rates 2-3% above Medicare averages. They're improving STAR ratings despite the rising difficulty.

Ready to stop the bleeding and build a high-performing adherence strategy?

Learn more at actualmeds.com/solutions#adherence-stars or contact Brian Bainter at bbainter@actualmeds.com to start optimizing your STAR ratings today.

Topics Covered

  • News

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