Medicare star ratings: how they work + how to compare plans
Medicare star system
If you become eligible for Medicare this year or are considering switching plans when open enrollment season starts, our guide will help you decide which plan is best for you. Before you do, it’s important to know that Medicare uses a 5-star rating system to measure the quality of health insurance plans.
Plans with higher Medicare star ratings have proven higher quality (which may mean more doctors in-network, better care, or more care options), while lower ratings have not. Knowing what these Medicare star ratings mean and how to utilize them in your search for the best health insurance can be a massive help in deciding which plan is best for you.
What are the Medicare star ratings?
Medicare uses a system that assigns each plan a star rating from one to five stars. Plans with higher ratings offer higher quality, meaning they offer better care at lower costs through well-known providers and hospitals in their network.
They also offer more favorable customer service hours and higher satisfaction ratings from beneficiaries who have used them in the past year. Although 5-star plans are ideal, this rating is extremely difficult to achieve.
The star rating breakdown:
Five stars
The highest possible rating given by Medicare and means that beneficiaries will have access to a wide range of doctors, hospitals, and other providers in their network without cost-sharing or restrictions. This includes specialists such as cardiologists and cancer surgeons—even if they're outside your plan's local area.
You'll also be able to see all pricing information before you sign up for coverage, so you'll know how much each doctor visit costs ahead of time. And when it comes time to go into the hospital or need nursing home care, there won't likely be any surprises about what bills might come due since everything should already be spelled out in your plan.
Four stars
The next highest rating and means that beneficiaries will continue to have access to a broad range of doctors, hospitals, and providers in their network. This plan is considered above average and the highest number of Medicare plans fall into this rating.
Three stars
Three stars indicate that beneficiaries can choose from more than one provider within their plan's healthcare providers network. This includes specialists such as cardiologists and cancer surgeons—even if they're outside your plan's local area. You'll also be able to see pricing information before you sign up for coverage, so you'll know how much each doctor visit costs ahead of time.
Two stars
Two stars indicate that beneficiaries can choose from one provider within their plan's network without cost-sharing or restrictions.
One star
One star means the beneficiary will have access to only a single, non-network physician in their region who is contracted with Medicare.
What Medicare Advantage Plans have a 5-star rating?
Like we said, 5-star ratings are very hard to achieve for insurance companies and the Medicare advantage plan they offer. This is done intentionally to keep competition among plans. Sometimes it's something as medial as not offering transportation coverage that can drag down their 5-star to a 4.5. Plus, a lot of their fate lies in the hands of their members, who leave reviews each year indicating how well they met all levels of care.
Medicare Advantage plans have more stringent criteria to meet their star rating than other Medicare Plans, such as prescription drug coverage. In general, you can change your plan or enroll in a new one only during a Special Enrollment Period. Their star rating is based on how well they do in each of the following categories:
- Staying healthy (member access to screenings, tests, vaccines, etc.)
- Chronic condition management
- Overall satisfaction with care and health plan responsiveness
- Member complaints and members leaving the health plan
- Customer service rating
Despite these regulations and categories, there are plenty of Medicare Advantage plans with near five-star ratings to their beneficiaries. Therefore, including Medicare Advantage plans in your search for the best health insurance can be a wise decision.
Get Help From The Pros
As you search for the right Medicare plan, and Medicaid services, you can compare plans based on your specific needs, plus filter by drug coverage, special coverages, and star rating at Medicare.gov. Our Ōmcare customer care team is available 24/7 to answer any questions and provide the expert support you and your loved ones need.
Connected care and remote patient monitoring prove to be cost-effective methods to improve patient outcomes, medication adherence, and patient satisfaction
Exclusive technology from Ōmcare aims to eliminate common breakdown in chain of communication between patients, providers, and family caregivers.
By Lisa Lavin, founder and CEO, Ōmcare
The United States population is aging and, in the process, they will require more in the way of long-term care support and services. In fact, it’s estimated that between 2015 and 2050, the senior population will more than triple, with half of these individuals expected to need long-term care, which will come from either skilled nursing facilities or from adult children or family members. According to projections produced by the Congressional Budget Office, due to population growth, long-term care expenses could more than double from 1.3% of gross domestic product (GDP) in 2010 to 3% of GDP in 2050.[i]
In either scenario, the high cost of care creates financial hardships for individuals and families, taxes the personal time and relationships between family members, and can even impact the professional lives of caregivers. According to a 2016 report by AARP, family caregivers are spending roughly $7,000 per year ($6,954) in all out-of-pocket costs related to caregiving: household expenses, medical expenses, and more.[ii] The average family caregiver spends roughly $7,000 per year, or nearly 20 percent of their annual income, on out-of-pocket costs, according to AARP estimates.[i]
A common issue that often complicates caregiving, influences patient outcomes, and contributes to rising costs, is lack of medication adherence by patients. Nonadherence accounts for up to 50% of treatment failures, around 125,000 deaths, and up to 25% of hospitalizations each year in the United States.[iii] Studies show that 26% of readmissions are potentially preventable and medication-related, the most common of which was nonadherence due to patient choice (23.8%).[iv]
According to estimates by the IMS Institute, better medication management could produce $213 billion in savings annually, of which $105 billion would be from improved adherence.[v]
The ripple effect of caregiving needs
While the impact of increased caregiving needs for the aging population are many, two of the most significant areas of impact are related to cost and caregivers.
Financial impact. With healthcare costs set to hit more than $2.3 trillion, the need for more cost-efficient care has never been more important. Consider the fact that the annual median cost for nursing facilities ($97,455 for a private room) is more than double the median income of older households ($42,113). Likewise, according to the National Association of Home Care, the average cost of care from a skilled nursing facility is $544 dollars per day, while the average cost of home health care per visit is $132 dollars.[i]
On average, an American turning 65 today will incur $138,000 in future long-term care costs.[ii] Families will pay about half of the costs themselves out-of-pocket, with the rest covered by public programs and private insurance.[x] While most people with long-term care needs will spend relatively little on their care, about one in six (17%) will spend at least $100,000 out-of-pocket.[i]
Caregiver impact. Approximately 35 million Americans provided unpaid care to an adult age 50 or older in 2015. The vast majority (85%) were caregivers for a relative, primarily an aging parent.[vi] The term ‘sandwich generation' – the label used to describe adult children who are simultaneously caring for their children and their aging parents – is becoming so commonplace that it was added to the Merriam-Webster Dictionary in 2006. However, the dictionary fails to mention the heavy financial and emotional stress that being a part of this generation can cause on caregivers.[vi] Caregivers often experience the following:
- Caregivers report high rates of depressive symptoms and mental health problems, compounded with the physical strain of caring for someone who cannot perform activities of daily living, such as bathing, grooming and other personal care activities.[vii]
- 6 out of 10 (61%) caregivers experience at least one change in their employment due to caregiving such as cutting back work hours, taking a leave of absence, receiving a warning about performance/attendance, among others.[viii]
- 49% arrive to their place of work late/leave early/take time off, 15% take a leave of absence, 14% reduce their hours/take a demotion, 7% receive a warning about performance/attendance, 5% turn down a promotion, 4% choose early retirement, 3% lose job benefits, and 6% give up working entirely.[viii]
Further exacerbating these factors is the poor or inconsistent communication that occurs between patients, caregivers, and healthcare providers. A study by the Accreditation Council for Graduate Medical Education (ACGME) found that 69% of health care providers do not have a standardized hand-off process – a real-time process of passing patient information from one caregiver to another – and only 20% have some standardization. This lack of process can create inaccuracies that lead to extended stays in clinical facilities or that complicate medication and therapy adherence outcomes.[ix]
Telehealth solutions impact all stages of care
Amidst rising costs and changing demographic needs, telemedicine has emerged as a viable solution for doctors, patients, employers, and insurance providers to cut costs and save money.[x] It’s no surprise then that utilization of telemedicine is growing. According to Deloitte, physicians conducted about 100 million telemedicine appointments globally in 2014, which generated potential savings of more than $5 billion when compared to the cost of in-person doctor visits.[x] From 2014 to 2018, the use of non-hospital-based provider-to-patient telehealth grew 1,393%.[xi]
New telehealth and remote monitoring technologies are fundamentally changing the way people interact with health care.[xii]
Remote patient monitoring
Remote patient monitoring is a digital health solution that captures and records patient physiologic data outside of a traditional health care environment.[xii] As providers increasingly turn to remote patient monitoring technology to improve patient outcomes, limit costs, and cut down on using more expensive services, healthcare industry newcomers and legacy players alike are vying for a piece of this growing market.[xiii]
Remote patient monitoring is particularly helpful in managing chronic conditions and improving medication adherence because it provides visibility into patients’ lives outside of their scheduled appointments, which has historically been a barrier to timely and effective diagnosis and management.[xiii]
With data collected over time, care team members can manage and treat chronic conditions in a way that is effective, timely, and realistic to the patient and caregiver’s lifestyles. The data generated through this approach can help facilitate conversations between patients and physicians and facilitate opportunities to intervene quickly to avoid complications.[xiii]
In addition to providing care teams with better, more actionable information earlier, remote patient monitoring has been praised for engaging patients in their own care by providing them access to their own data so they can better understand the impact of their treatment and advocate for their medical needs.[xiv]
Connect caregivers with the right technology
From tracking vital signs with remote monitoring devices to communicating quickly with a nurse through a web portal to receiving on-the-spot care from a doctor via video chat, telehealth aims to make life easier.[xiv]
The right technology can give health care providers and caregivers a means of communication that is essential to improving patient outcomes. For example, patient monitoring programs that allow virtual check-ins enable patients to extend the duration between doctor's visits or unplanned hospital stays. Meanwhile, a KLAS Research report surveying 25 healthcare organizations found 38% of healthcare organizations using remote patient monitoring programs for chronic disease management reported reduced admissions, while 17% cited cost reductions.[xiii]
Older adults with long-term care needs should be able to live independently as they age while limiting stress on family caregivers. Telehealth strategies can support this process by improving access to care and ensuring its quality, while reducing the strain put on family members by increased time requirements, added mental and emotional stress, and financial burdens of providing long-term care to an aging loved one. The right technology can address these issues and allow for loved ones to age gracefully and in their best health.
About Ōmcare
Ōmcare is a health technology company aspiring to extend the reach of the caregiver, increase medication adherence, and to improve treatment outcomes by harnessing the power of remote care. We aim to achieve this through our proprietary interactive technologies - promising right pill, right time, right person. By partnering with pharmacies, payers, providers, and family caregivers, our vision is to help people live healthier, more vibrant, independent lives.
References
[i] "Long-Term Services And Supports For Older Americans: Risks And Financing Research Brief". ASPE, 2019, https://aspe.hhs.gov/basic-report/long-term-services-and-supports-older-americans-risks-and-financing-research-brief.
[ii] "Caregiving Innovation Frontiers". Aarp.Org, 2019, https://www.aarp.org/content/dam/aarp/home-and-family/personal-technology/2017/08/caregiving-innovation-frontiers-2017-aarp.pdf.
[iii] Kim, Jennifer. "Medication Adherence: The Elephant In The Room". Uspharmacist.Com, 2019, https://www.uspharmacist.com/article/medication-adherence-the-elephant-in-the-room.
[iv] "Up To 26% Of Hospital Readmissions Are Preventable And Medication-Based". Drug Topics, 2019, https://www.drugtopics.com/drug-topics/news/26-hospital-readmissions-are-preventable-and-medication-based.
[v] IMS Institute for Healthcare Informatics, “Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly,” June 2013
[vi] "The Sandwich Generation | What Is The Sandwich Generation?". Seniorliving.Org, 2019, https://www.seniorliving.org/caregiving/sandwich-generation/.
[vii] "Caregiver Health | Family Caregiver Alliance". Caregiver.Org, 2019, https://www.caregiver.org/caregiver-health.
[viii] "Caregiving In The U.S.". Aarp.Org, 2019, https://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf.
[ix] Wagner R, et al. CLER 2016 National Report of Findings, Issue Brief #5: Care Transitions. Chicago, Illinois: Accreditation Council for Graduate Medical Education, March 2017.
[x] "Telemedicine Research Papers: Trends In Healthcare - Evisit". Evisit, 2019, https://evisit.com/resources/telemedicine-trends/.
[xi] fairhealth.org. (2019). A Multilayered Analysis of Telehealth. [online] Available at: https://s3.amazonaws.com/media2.fairhealth.org/whitepaper/asset/A%20Multilayered%20Analysis%20of%20Telehealth%20-%20A%20FAIR%20Health%20White%20Paper.pdf.
[xii] "Digital Health Implementation Playbook". Ama-Assn.Org, 2019, https://www.ama-assn.org/system/files/2018-12/digital-health-implementation-playbook-REV1.pdf
[xiii] "The Technology, Devices, And Benefits Of The Growing Remote Patient Monitoring Market". Business Insider, 2019, https://www.businessinsider.com/remote-patient-monitoring-industry-explained.
[xiv] "Telehealth And Seniors | Updated For 2019 | Aginginplace.Org". Aginginplace.Org, 2019, https://www.aginginplace.org/telehealth-and-seniors/.