Welcome back to The Healthcare STARcast with host Subbu Ramalingam. In today’s episode, we dive deep into the waves shaking up the Medicare Advantage world, especially the storm surrounding the Star Ratings system. Just weeks after the July 4th holiday, headline-grabbing lawsuits and court decisions have placed CMS and health plans in the legal crosshairs, forcing rule recalculations and questioning the very framework of quality ratings.
We’re joined by Mark Newsom, former CMS executive and now an industry consultant, who brings a front-row perspective to the chaos. Mark unpacks the litigation saga, from high-profile court victories and defeats to the broader impact of the recent Loper Bright Supreme Court ruling that’s fueling even more challenges against federal health agencies. We’ll break down what’s at stake for payers, providers, and beneficiaries, and hear Mark’s take on how Star Ratings and Medicare Advantage itself could be transformed in the years ahead.
With so much in flux, this is a defining leadership moment for industry professionals operating at every level. Whether you’re managing member experience, responsible for board communications, or strategizing on compliance and risk, Mark has practical advice for how operators and leaders can navigate this period of uncertainty. Stay tuned as we untangle the latest and look towards what’s next for the future of MA Star Ratings.
Timestamps:
00:00 Discussing star rating lawsuits
05:10 Background on the Loper Bright Case
06:27 Challenges in administrative law cases
11:25 CMS oversight and audit measures
12:52 Medicare Advantage guidance challenges
17:38 Discussing Medicare Part D criticism
19:35 Clover litigation and broader implications
23:19 Understanding survey response issues
28:50 Lobbying CMS for higher ratings
31:17 CMS as a perceived mystery
36:04 Focusing on quality over metrics
38:16 Discussing litigation planning steps
42:20 Discussing Changes in Medicare Advantage
43:46 Wrap-up and future discussions
Unpacking Medicare Advantage Lawsuits and STAR Ratings: Insights from Healthcare STARcast
Introduction to the Current State of Medicare Advantage and STAR Ratings
The Medicare Advantage landscape is experiencing significant upheaval, as highlighted in the Healthcare STARcast, featuring Mark Newsom. Recent years have seen a steady rise in legal challenges against the Centers for Medicare & Medicaid Services (CMS), particularly surrounding the STAR rating system used to evaluate health plans. In this episode, listeners gain a comprehensive view of the ongoing lawsuits, CMS recalculations, and what these mean for payers, providers, and beneficiaries.
A Wave of Lawsuits: How Litigation is Shaping Medicare Advantage
For those in the Medicare Advantage industry, litigation has become a "permanent feature" of the program, based on insights shared by Mark Newsom. Instead of alignment across the industry, individual plans now pursue legal paths that benefit their specific interests rather than the broader program. This fragmented approach complicates CMS's task of maintaining program integrity and fairness.
Notable lawsuits, including those involving United Health, Humana, Clover, Carefrees, and Elevance, illustrate the diverse and sometimes conflicting nature of these legal challenges. Some cases focus on statistical and rounding errors, while others, like Clover's significant victory in Georgia, question CMS's very authority to use certain data sources for rankings.
The Impact of Supreme Court Decisions on CMS Authority
A pivotal development impacting these legal dynamics is the Supreme Court’s Loper Bright decision, which overturned decades of judicial deference to executive branch expertise. As Mark Newsom explained, this opens the door for organizations to more aggressively sue CMS if they disagree with regulatory decisions, increasing uncertainty and complexity around the STAR program.
This shift has disrupted the balance in which plans generally presented a unified front on issues like payment rates and risk adjustments. When it comes to STAR ratings, however, plans often act in their own self-interest, attacking or defending metrics that favor their position.
The Clover Lawsuit: A Turning Point in Quality Bonus Payments
The episode takes a deep dive into the implications of the Clover lawsuit, where a federal judge ruled that CMS lacked authority to use data from certain measures when determining plan bonuses. As Mark Newsom detailed, CMS’s response was to extend recalculations beyond Clover to all plans, essentially preempting future litigation over fairness.
While some in the industry may celebrate this as a victory, Mark Newsom cautioned that requiring all guidance and rule changes to go through full notice and comment rulemaking will reduce the system’s flexibility. This could hinder both CMS and the plans’ ability to quickly adapt to technical or operational challenges.
Operational and Political Implications for Plans and Leaders
The STAR rating lawsuits have wide-ranging operational and political repercussions. As Mark Newsom noted, both parties in Congress remain skeptical of Medicare Advantage practices, and the constant legal disputes may prompt legislative intervention.
Plans are left with significant uncertainty for their boards, leadership, and value-based contracting partners. Mark Newsom’s advice for industry leaders is to tune out the noise and focus on measures they can control, particularly those pertaining to HEDIS, CAHPS, and HOS. Excellence in member experience and clinical quality remains essential, regardless of how litigation impacts specific measures.
A Leadership Moment for STAR and Medicare Advantage Professionals
The episode closes with a call to action: current ambiguity creates a "leadership moment" for STAR and Medicare Advantage professionals. By focusing on their core mission, actively engaging in the measurement development process, and scenario-planning for various legal and regulatory outcomes, industry leaders can navigate this period of transformation and uncertainty.
Conclusion: Embrace Change and Lead Forward
The Healthcare STARcast is an essential listen for anyone involved in Medicare Advantage or STAR ratings. Mark Newsom’s in-depth analysis guides listeners through the tangled web of litigation and regulation, offering practical advice for payers, providers, and policy advocates alike. The future of STAR ratings and Medicare Advantage will be shaped by the collaborative efforts of leaders willing to adapt, innovate, and always prioritize the beneficiary.
Show Website - https://healthcarestarcast.com/
Subbu Ramalingam - Show Host - Linkedin - https://www.linkedin.com/in/subburamalingam/
FloWise Leadership - https://flowiseleadership.com/
ViVega Business Services - https://www.vivega.co/
ATTAC Consulting Group - https://www.attacconsulting.com/
Media Partner - TopHealth - https://tophealth.care/
“Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”