The recent court ruling in Clover Insurance Co. v. HHS has sparked widespread discussion across the Medicare Advantage industry. Much of the conversation has centered on Medicare Star Ratings and which quality measures may ultimately remain in the program.
But for health plans, the more important question is: Should medication adherence and optimization remain strategic priorities, even if quality measures change?
The answer is unequivocally yes.
Medication optimization has always delivered value beyond Star Ratings. It remains one of the most effective ways to improve outcomes for members with chronic disease while reducing avoidable healthcare utilization and total cost of care.
The stakes extend far beyond quality scores. Medication-related problems are estimated to contribute to hundreds of billions of dollars in avoidable healthcare costs annually, driven by preventable hospitalizations, emergency visits, and complications from non-optimized medication use. As we'll explore below, those results remain just as relevant regardless of how quality measures evolve.
Whether CMS changes how quality is measured does not change the underlying clinical and economic value of helping members receive the right medications and take them consistently. For health plans, medication optimization is fundamentally a clinical strategy and not just a quality reporting strategy.
The Clover decision invalidated 20 Medicare Advantage quality measures—not because the court found the measures clinically unimportant, but because it found legal flaws in how the Centers for Medicare & Medicaid Services (CMS) implemented them. Some measures relied on data sources outside the three congressionally authorized quality improvement programs (HEDIS, CAHPS, and HOS), while others were implemented through Technical Specifications and other guidance without the required notice-and-comment rulemaking. The court concluded that these actions exceeded CMS's statutory authority.
Importantly, the ruling did not conclude that medication-use quality measures lack clinical value.
Regardless of how quality measures evolve, medication adherence remains one of the strongest predictors of outcomes for members with chronic disease. CMS's proposed MY2027 Star Ratings would return these measures to triple weighting, reflecting their importance in improving outcomes for chronic conditions.
Measured by Proportion of Days Covered (PDC), adherence measures consistently rank among the lowest-performing Medicare Star Rating measures. Their persistent underperformance underscores how difficult it is for patients to start and stay on therapy, and why improving adherence remains one of the most impactful opportunities to reduce avoidable complications, hospitalizations, and total cost of care.
The clinical impact of adherence is well established:
Members with unresolved medication problems, like unmanaged polypharmacy, also experience higher rates of hospitalization, adverse events, and avoidable healthcare spending. For example, a nationwide cohort study of more than three million older adults found that polypharmacy was associated with significantly higher rates of hospitalization and all-cause mortality, with risk increasing as the number of medications increased. Likewise, the National Institute on Aging and the American Geriatrics Society's Beers Criteria identify inappropriate polypharmacy—particularly involving CNS-active and anticholinergic medications—as a major patient safety concern because of its association with falls, cognitive impairment, and functional decline.
Those clinical risks and their associated costs demonstrate why medication measures matter beyond any individual quality program. Whether medication quality measures appear in Star Ratings, HEDIS, Display Pages, or another quality program, the objective is still to help patients receive the right medications, use them appropriately, and avoid preventable complications.
Arine's Medication AI platform analyzes medication use across millions of members to identify gaps in care, adherence barriers, and opportunities for optimization. Across an analysis of six health plans, members adherent to diabetes, RASA, or statin medications had measurable, consistent advantages over nonadherent members with similar clinical profiles:
We also find evidence that reducing polypharmacy, including concurrent opioid and benzodiazepine use, can reduce total cost of care by 10-15%. For higher-risk members specifically, MTM interventions reduce total cost of care by 7%. Arine's findings are consistent with the above findings from the literature.
Regardless of whether a metric appears in Medicare Star Ratings or not the underlying clinical driver is the same:
Patients who take the right medication, correctly and consistently, have fewer preventable hospitalizations.
The most consequential error a Medicare Advantage plan could make right now is treating the Clover ruling as a reason to deprioritize medication management programs. The members who were nonadherent, on inappropriate medication combinations, or missing statin therapy before the ruling are in the same clinical situation today. The measure's status in a CMS formula doesn’t change their risk profile.
The ruling doesn't change the fact that medication issues still lead to hospitalizations, ED visits, and higher healthcare costs. If plans reduce their focus on medication optimization, they'll still bear those costs—even if they're no longer reflected in Star Ratings.
Rather than viewing the Clover ruling as a reason to scale back medication management efforts, health plans should see it as an opportunity to reinforce the strategies that consistently improve clinical and financial outcomes. The evidence hasn't changed. Optimizing medication use remains one of the most effective ways to prevent avoidable complications, improve member health, and reduce total cost of care.
Successful medication strategies focus on these priorities:
The health plans that continue investing in medication optimization will be better positioned to improve member outcomes, reduce avoidable medical costs, and succeed regardless of how quality programs evolve.
The Clover ruling may influence future CMS rulemaking, congressional action, or even the structure of the Medicare Star Ratings program. But it should not change the industry's commitment to medication optimization.
Because regardless of how CMS measures quality, better medication use still leads to better health.
No. The ruling addressed CMS's authority to use certain data sources and not whether medication adherence improves clinical outcomes. The clinical evidence supporting medication adherence remains strong.
Yes. Medication optimization reduces preventable hospitalizations, emergency department visits, and total medical costs while improving outcomes, especially for members with chronic conditions.
Arine’s Medication AI transforms fragmented clinical and medication data into actionable insights for health plans and care teams. By learning from millions of medication decisions, interventions, and outcomes, it identifies the members most likely to benefit and prioritizes the actions with the greatest potential impact. This enables pharmacists and clinicians to focus on improving outcomes, closing care gaps, and reducing avoidable costs at scale.
No. Medication-related problems drive unnecessary costs across Medicare, Medicaid, and Commercial populations. Optimizing medication use improves outcomes across all lines of business.