Payer analytic spotlight

The Medicare Star Ratings system, developed by the Centers for Medicare & Medicaid Services (CMS), evaluates the quality of Medicare Advantage (Part C) and Prescription Drug (Part D) plans using a 1–5 star scale. It guides consumer choice, incentivizes plan performance, and aligns with the “Meaningful Measures” framework focused on patient-centered, outcome-driven care. 

2026 updates: A shift toward outcomes and equity 

The 2026 Medicare Advantage and Part D Star Ratings reflect a major shift toward performance, equity, and outcome-driven care. Stricter cut-points made high scores harder to achieve, yet 18 plans earned 5 stars—up from 7 last year. While overall improvement was modest, most plans maintained their ratings, indicating stabilization after years of decline. This may reflect ongoing adjustment to CMS’ tougher benchmarks and revised scoring methodology. 

Why Star Ratings matter 

As Medicare shifts focus from patient experience to measurable outcomes—like chronic condition management, medication adherence, and preventive screenings—plans must deliver meaningful results, not just incremental gains. With millions at stake, investing in analytics, member engagement, and provider alignment is critical. 

Star Ratings support and drive: 

• Consumer choice: Simplify healthcare data so beneficiaries can compare plans by quality and outcomes
• Financial rewards: Plans with ≥4 stars earn Quality Bonus Payments to enhance benefits or lower premiums
• Competitive edge: High ratings attract and retain members; low ratings risk enrollment loss or contract termination 

Data-driven performance 

Given the complexity of Star Rating metrics, plans benefit from investing in solutions that automate reporting and align with CMS’ evolving criteria. Real-time claims data enables continuous performance monitoring and reduces errors. Patient-level metrics help identify and close care gaps proactively, focusing on high-impact measures. 

As CMS emphasizes equity for underserved populations, solutions should integrate with data like Social Determinants of Health (SDOH). Comprehensive integration supports tailored outreach, disparity tracking, and faster, more informed decision-making. 

The Medicare Star Ratings system is more than a scorecard—it drives quality, equity, and transparency.  

To boost Star Ratings and drive better outcomes, it’s essential to have the right data assets, data integration to highlight and reflect equity, and enriched analytics that deliver near real-time insights, including NCQA certified measures. These assets will empower you to enhance member satisfaction, improve financial performance, and drive better outcomes across all populations. 

Check out Truven’s data sheet here for how our clients leverage our analytics on demand to surface insights faster for greater impact.  

The Institute for Clinical and Economic Review (ICER) has released its highly anticipated draft evidence report evaluating the effectiveness and value of three obesity medications: injectable semaglutide (Ozempic®, Wegovy®), oral semaglutide (Rybelsus®), and tirzepatide (Mounjaro®, Zepbound®). The report delivers crucial insights for commercial payers and healthcare purchasers on the rapidly evolving landscape of obesity pharmacotherapy. As employers and health plans grapple with mounting demand for effective weight‐loss treatments, ICER’s comprehensive evaluation of semaglutide and tirzepatide products underscores both clinical promise and implementation challenges. 

The report affirms that injectable semaglutide, oral semaglutide, and tirzepatide hold top‐tier evidence ratings (A) when compared with lifestyle modification alone. However, ICER flags a significant evidence gap in direct comparisons between these two leading GLP-1 receptor agonists. Moreover, injectables outperform oral semaglutide by a wide margin, with the latter carrying a C- rating for weight‐loss efficacy. As two new oral semaglutide formulations are expected to launch in early 2026, payers will face a pivotal decision: whether to pre‐emptively steer coverage toward injectables until robust head-to-head and real-world data emerge, while preserving medical exceptions for high-need patients, or to allow broader patient choice. 

Adherence and persistence present another critical hurdle. ICER’s analysis shows only 36% of patients remain adherent to injectable semaglutide at one year—and just 25% for oral semaglutide. For tirzepatide, measured at six months, persistence ranges from 54% to 74%. These figures mirror Merative studies and emphasize the urgency for payers to bolster wrap-around care programs, patient engagement initiatives, and adherence incentives as they finalize benefit designs for 2026. 

Despite high list prices, ICER assigns both semaglutide and tirzepatide regimens strong value ratings, deeming them cost-effective at a threshold of $100,000 per quality-adjusted life year (QALY). With typical net prices after rebates falling roughly 50% below list, payers can present these value assessments to executive leadership, alongside emerging outcome data, to support broadened coverage strategies that balance access, clinical impact, and financial sustainability. 

ICER’s findings offer a roadmap for employers, health plans, and healthcare purchasers to balance clinical value with financial sustainability. Commercial payers can leverage the ICER findings to craft targeted coverage policies, optimize benefit designs, and drive better clinical and financial outcomes. Below are key ways these insights can shape payer decision-making in 2026 and beyond: 

Focus coverage on patients with obesity-related comorbidities (e.g., cardiovascular disease, sleep apnea, prediabetes) where the drugs show the greatest benefit and cost-effectiveness. 

Prioritize injectable semaglutide and tirzepatide on preferred tiers. By granting injectables preferred formulary placement, payers align coverage with the strongest evidence ratings (A) and steer utilization toward higher-efficacy treatments. 

Implement cautious onboarding of new oral semaglutide. Institute a coverage hold or higher cost share (e.g., Non-Preferred tier) on oral semaglutide products at launch, with automatic review six to 12 months post-market when head-to-head data become available. Allow physician override for patients intolerant to injectables. 

Use step-therapy pathways: require documented lifestyle modification efforts first, followed by injectable GLP-1 initiation, before permitting oral formulations. This balances cost management with evidence-based escalation of care. 

Negotiate outcomes-based agreements with manufacturers and care management programs, tying reimbursement to sustained weight loss, reduction in comorbidities, or adherence metrics. 

ICER highlights disparities in access and outcomes among Black and Hispanic populations. Payers should ensure culturally competent care and equitable coverage policies. 

With only 25–36% of patients remaining on therapy at one year, payers should invest in patient support programs to improve persistence and maximize ROI. Enhance wrap-around care programs, build or expand coaching, digital reminders, and care navigation specifically for GLP-1 therapies. Some payers are reporting that requiring care programs for GLP-1 access can jeopardize rebates for those medications – consider alternative options, such as tying participation to reduced member cost share or offering participation incentives through HSA contributions. Deploy real-time monitoring and outreach including integrating pharmacy data feeds into care management workflows so case managers can reach out when refill gaps appear. 

Medicare price negotiations and direct-to-consumer programs (e.g., LillyDirect, NovoCare) may shift market dynamics. Payers should stay agile in response to pricing changes and use all available benchmarks and data for price comparisons – this includes real-world data sets (e.g., MarketScan) and government mandated transparency reporting, such as RxDC reports. 

Present value-based dashboards and share ICER’s cost-effectiveness ratings alongside internal adherence and outcomes data to executive leadership, underscoring both clinical impact and budget neutrality. Forecast long-term savings by modeling downstream avoided costs (e.g., diabetes, cardiovascular events) tied to sustained weight loss, helping CFOs justify upfront pharmacy investments. 

ICER’s report underscores the transformative potential of semaglutide and tirzepatide in obesity management. For payers, the challenge lies in translating clinical and economic value into sustainable coverage strategies—balancing innovation with affordability. Commercial payers should use this ICER draft report as both a roadmap and a risk-mitigation tool. By embedding these tactics into formulary management, contracting, benefit design, and clinical policy, payers can harness the promise of semaglutide and tirzepatide while mitigating risks around adherence, cost, and evidence gaps. This proactive framework positions payers to deliver high-value obesity care, helping employers and health plans navigate GLP-1s into 2026 with confidence—securing meaningful clinical outcomes for members while maintaining fiscal discipline. 

In our last Spotlight, Truven asked for your input on the prior authorization process and potential areas for improvement. The Q2 2025 client survey revealed that over 60% of respondents believe prior authorization is a critical tool for managing healthcare costs. However, many expressed concern that changes to the process could lead to increased healthcare spending—especially during a time when costs are already high. 

Transparency and member support 

When asked whether members are provided with the tools they need to navigate the prior authorization process and understand service denials, responses were mixed: 

• 25% agreed that adequate tools are provided
• 25% disagreed
• 50% remained neutral 

This suggests an opportunity to enhance transparency and member education. 

Denial reversals 

Survey responses also varied regarding the percentage of prior authorization denials that are eventually approved: 

• 50% of respondents estimated that 11–20% of denials are later overturned
• 12.5% reported either very low (less than 10%) or very high (more than 90%) reversal rates 

This wide range highlights inconsistencies in how denials are handled and perceived across organizations. 

Opportunities for improvement 

Your Truven account team is here to support you in evaluating and refining your prior authorization processes. Potential areas of focus include: 

• Analyzing denial reasons to streamline approvals,
• Reducing delays between submission and approval to minimize care disruption,
• Comparing authorized versus rendered services to ensure quality care delivery. 

Reach out to your Truven team to explore tailored strategies that align with your organization’s goals. 

In last quarter’s Spotlight, we noted that one of the largest cost drivers for payers was mental health and substance use services, with an increase in allowed payments of 14.6% per member (15.5% per contract). Nearly one in five adults live with a mental health condition, and there is an estimated $44B loss in workplace productivity due to depression. Not only can mental health disorders be debilitating on their own, but they are often comorbid with chronic physical conditions and present a need for increased focus on whole person care. 

Mental health and chronic conditions 

Although average per patient costs for depression treatment are equivalent, data from MarketScan®, a Truven data solution,  shows prevalence rates for depression that are 36% higher than the total population for patients with cardiodiabetes conditions (CAD, CHF, lipid disorders, diabetes, or obesity) and 14% higher for patients with a cancer diagnosis. 

Comorbid mental health concerns can make it difficult for patients to manage their underlying conditions and can lead to worse outcomes. It’s important to make sure that members understand their coverage options, especially as in person mental health treatment has become harder to access. In particular, in addition to depression medications themselves leading to possible weight gain, depression symptoms can lead to difficulty maintaining medication regimens and making necessary lifestyle changes that reduce cardiodiabetes risk. For example, persistence to a GLP-1s regimen may be difficult due to mental health struggles despite potential of weight loss contributing to mental health improvement. Cancer patients with depression may need different treatment pathways for depression treatment as there may be drug interactions or side effects that can make standard treatments less palatable. 

What you can do 

• Program solutions 
  • Work with your vendors (insurance carriers, point solutions, leave carriers, and EAP vendors) to ensure they are cross-referencing. A patient newly diagnosed with a chronic condition should be aware of (and ideally, navigated to) available mental health resources. 
    Consider technology solutions or telemedicine solutions that can help members manage adherence and address common barriers .
• Communications solutions
  • Promote general education and awareness around access to mental health services to all employees, particularly low- or no-cost sharing resources, such as initial counseling services through an employee assistance program (EAP).
• Provider solutions
  • Identify the providers that treat most of the patients to talk about how personalized treatment plans can be incorporated for members.  
  • Ensure that mental health services are included and  promoted for any employer-sponsored providers such as ACOs or on/near-site clinics.
• Proactive identification
  • Identify the patients at highest risk for mental health conditions based on comorbid conditions, demographics, and sociodemographics to focus vendor resources on the right members and identify regions for targeted programs/pilot interventions. 

Care quality 

Engaging members with mental health services is just the first step. Continue to work with your carriers and provider community to ensure ongoing access to high quality providers, including tracking compliance with evidence-based treatment, and maintaining appropriate access standards. Payers can track the acuity level of new patient interactions to understand program success. For instance, ensuring that higher percentages of patients have an initial encounter with a low-acuity mental health provider (EAP, counselors, mental health apps)_vs high acuity providers (psychiatrist, emergency department, inpatient admission) and that over time, visits with lower acuity providers increase while higher acuity utilization shows a reduction. 

References:  

https://www.nimh.nih.gov/health/statistics/mental-illness  
https://secureservercdn.net/198.71.233.214/e47.77e.myftpupload.com/wp-content/uploads/2020/09/OMaW_Tufts-Study_High-Cost-of-Mental-Disorders-1.pdf 
https://www.cdc.gov/diabetes/living-with/mental-health.html 
https://pmc.ncbi.nlm.nih.gov/articles/PMC4356432/#b2-ol-09-04-1509 
https://www.npr.org/sections/health-shots/2023/12/13/1218953789/most-americans-with-mental-health-needs-dont-get-treatment-report-finds 
https://www.businessgrouphealth.org/resources/2026-employer-health-care-strategy-survey-executive-summary 
https://www.businessgrouphealth.org/resources/2026-employer-health-care-strategy-survey-executive-summary 

As employers look to improve member outcomes and manage healthcare costs, many are looking to leverage Centers of Excellence (COEs). COEs are high-performing provider organizations recognized for delivering superior care in specific clinical areas—such as orthopedics, cardiology, bariatric surgery, and maternity—based on quality, efficiency, and patient experience metrics. COEs are often recognized through third-party accreditation programs and align well with value-based care initiatives. 

Utilizing COEs allows health plan sponsors to steer members toward providers with proven track records, potentially reducing variability in care and improving clinical outcomes. These centers often follow evidence-based protocols, have lower complication rates, and demonstrate better long-term results, which translates into lower total cost of care and higher member satisfaction. You can contract with COEs directly, through your health plan(s), or through third vendors that build and manage COE networks. 

Using Truven Health Insights, you can identify clinical focus areas in your plan experience where COEs can drive value. In addition to prevalence, utilization, and cost, you can identify the stage of a condition using disease staging to allow you to better align your members’ needs with a COE’s offerings.  

Evaluating outcomes for COE networks, or any benefit change, is important to ensure changes align with plan goals. When implementing this type of program it is helpful to assess baseline metrics, including quality outcomes, determine metrics to be used in an analysis, and set a target goal for improvement. Evaluation criteria should include: 

• Quality outcomes
• Cost efficiency, including travel or network costs if applicable
• Patient satisfaction
• Program/network utilization
• Provider accreditation and recognition

For more information on how Truven can support your organization in implementing and evaluating COE programs or networks, please connect with your account team. 

Health plans, brokers, and benefits consultants all have a responsibility to report health program performance to their employer group clients. But the way you deliver these reports can mean the difference between a routine task and a consultative relationship. How are you currently handing reporting in your own organization?  

In a recent webinar hosted by AHIP, Truven experts discussed how effective account group reporting (AGR), also known as employer group reporting, can transform your approach to client engagement. Our recent blog covers important considerations, including the build vs buy decision and requirements for an AGR solution. Here’s what to look for: 

1. Data accuracy and integrity: High-quality data is the foundation of effective AGR. Good reporting requires robust data models and ingestion capabilities to integrate data from multiple sources, such as claims, enrollment, pharmacy, and provider data. Ensuring data consistency and reducing human error are essential for building trust and delivering reliable insights. 
2. Integration of diverse data sources: The healthcare industry generates a wide variety of data, including health equity data, workers’ compensation, and financial data. AGR platforms must be flexible enough to accommodate these diverse data types, enabling deeper insights and opening new consulting opportunities.
3. Automation and configurability: Automated reporting reduces administrative burdens and allows analysts to focus on value-added tasks. Configurable platforms enable organizations to tailor reports to specific client needs, whether through interactive dashboards or static report packages. This personalization enhances the client experience and ensures that insights are actionable and relevant.
4. Advanced analytics: Advanced analytic models can help you uncover patterns, anticipate risks, and provide meaningful trends. Clinical groupers, classifiers, and benchmarks transform raw data into actionable intelligence, driving strategic decision-making.
5. Scalability: AGR solutions must be scalable to handle thousands of account groups and users while maintaining performance.  

The key is to deliver accurate, timely, and insightful reports. Traditional methods relying on spreadsheets and manual processes are no longer sufficient in today’s competitive and complex healthcare landscape. Instead, your reporting should be automated, scalable, and configurable to meet the diverse needs of clients. That’s how you can start to position yourself as a strategic advisor to your clients, providing actionable insights that strengthen client relationships. 

Enhancing the customer experience 

To deliver a superior customer experience, organizations should: 

• Design reports that tell a story, answering common questions and highlighting key insights.
• Use modern graphics and interactive features like filtering and drill-downs.
• Ensure reports are portable and easy to share.
• Automate report generation and delivery while allowing for pre-release reviews.

Ultimately, your reporting should empower clients with the insights they need to succeed. Read our blog and check out our on-demand webinar for more information.