On January 26, CMS released its latest Advanced Notice Methodological Changes for Calendar Year (CY) 2027 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. The release covers the removal of quality measures as well as two key changes that effectively reduce RAF score calculations. Risk bearing entities will face lower reimbursements across the board and a reduction in quality bonuses without any drop in real-world quality.
Fortunately, we’re here to help you make up the difference outside of clinical settings and address the social factors that avoidably worsen outcomes, increase costs, and artificially lower quality scores.
The advanced announcement includes two changes. First, a recalculation via denominators from 2020 to 2024 RAF trendlines, causing a -3.32% reduction for CY 2026 to 0.9%. There is an additional projection of another -1.53% in 2027 driven by a proposal to remove unlinked chart record continuity in a move to reduce retrospective upcoding.
Combined, both are expected to add $15.22B and $7.12b respectively in net savings for CMS, representing a minimum $22.34b reduction in value-based payments.
Historically, high Stars performance is margin protection from these reimbursement shakeups. Unfortunately, changes to Stars are making that much more difficult. The proposal assumes the removal of 12 quality measures for Stars performance. Seven on operational and administrative performance, three on process of care, and two on patient experience.
In 2025, MA plans received 12.7B in Quality Bonus Payments , averaging $372 PMPY; plans covering 100,000 enrollees achieving 4.5 Stars or higher on 42 quality measures spread across nine separate domains, would result in $37 million in quality bonus payments.
The proposed Stars changes would drop 158 contracts by 0.5 Stars, and 42 contracts would drop below 4.0 Stars, the qualifying threshold for bonuses.
That means losing millions in quality bonuses, facing increased member churn (75% of enrollees sit within the top percentile of plans that receive those bonuses), and even risk having contracts terminated by CMS .
Despite changes to the program, with the right data, Stars remains an effective avenue to protect margin and even improve it. That’s where we come in. Our SocialScape platform allows your organization to analyze the correlation between quality measure performance and social risk. By loading your members’ MA Stars measure results into SocialScape, you can analyze social risk at the measure and member level.
Socially Determined has three key pathways that help risk-bearing entities make a substantive difference for the health of members and the financial health of your organization.
SocialScape delivers individual social risk calculations aligned to quality measure results. As succinctly as possible: you can align a member’s clinical data with the social factors in their life that create barriers to care and gain insight on how to best intervene.
Member rosters can be ordered by cost and impact of intervening on those social factors, allowing for the most good to be done for the most people while producing incredible savings on costs of care.
Here’s where it gets even better: Quality measure results are also easily included in those data views.
Having quality measure results in SocialScape allows you to compare the social risk of your measure denominator population to measure numerator population and understand the social risks impacting measure results.
For example, your team can analyze the social risk for individual members in the denominator for breast cancer screening, compared to members in the numerator.
This data is presented alongside the individual non-clinical social risk factors likely impacting for that lack of screening.
SocialScape also supports continuous performance visibility at the population level with those same custom quality measure attributes. That means you always have a high-level view into the numerator and denominator of any group or population (including custom cohorts built out of members identified in individual views). This allows for not just progress monitoring, but an understanding of where to allocate resources to improve performance. At this level, social risk is still visualized, adding real insight into what needs to be addressed with those resources.
But knowing there’s a problem and intervening are two different things.
By now, you know who has and hasn’t had their breast cancer screening. You know how your organization is performing on that measure population and are monitoring different groups as needed. You have a team and resources dedicated to helping address whatever is stopping a member from coming in to get a mammogram.
Now you need to know what to do to meet the quality measure’s goals.
We’re the experts in non-clinical social risk. Obviously, we’ve got you covered.
In this final view, (Next Best Action), you see the top three benefit areas for any population, ranked by their likelihood of providing the greatest impact. Is there a group identified as facing transportation insecurity that’s a certain distance from a clinic that offers mammography? Resources can now be allocated to offer non-emergency medical transport. This works with any quality measure for any social risk.
Non-clinical factors account for 80% of health outcomes and have a similarly outsized impact on quality measure performance. With our help, those factors go from utterly untouchable to under your control. You can know who hasn’t been screened, both individually and at scale, what’s likely stopping them, and how to address it in the most cost-effective way.
At a time where the financial health and stability of organizations providing coverage for millions of Americans is in jeopardy from rapid policy shifts, we’re proud to give you the data and insights you need to change the entire game for you and your members.
There’s a lot more to discuss around how we can support your Stars performance. Let’s talk soon.