The final rule for CMS affecting star ratings focuses the results on – Are the health plans ready to take action?
The Centers for Medicare and Medicaid Services (CMS) final rule impacting star ratings suggest that the focus is on the obvious shift in health outcomes and equity, in which case success is less defined through the process, and more. Plans to modernize and upgrade their care models now will thrive in the ever-evolving stellar landscape.
This is what health plans need to be prioritized in current and future strategies.
Redesigning care around results – not checklist
Although operational metrics have always been part of the stars, CMS has steadily expanded its focus on clinical outcomes and now drives plans beyond the process. Plans need to reevaluate their current quality strategies and go beyond the metrics of the “check box” to focus on programs that close care gaps and drive real health impacts.
The National Council on Quality Assurance (NCQA) recently updated its colorectal cancer screening measures, including follow-up colonoscopy after testing based on fecal abnormalities. This is an important move from simply tracking who performed screening to determine whether appropriate diagnostic follow-up was performed. Although this measure has not been included in the CMS star rating program, it is consistent with the direction of the CMS star rating measurement: focusing on closed care rings and meaningful results. As CMS stays closer to NCQA’s guidance, I expect similar evolutions to affect future star scores. These changes are not only technical, but also have the potential to save lives.
Reevaluating the procedures related to stars through the resulting lens. Are you following up on follow-up events after the screening? If not, it’s time to rethink your data model and care workflow. More importantly, focus on core clinical areas such as diabetes, hypertension and kidney disease, and improve care coordination among members with multiple diseases.
Make digital quality infrastructure a priority
The expansion of electronic clinical data systems (ECDs) and API-based reporting has become a strategic priority. CMS has begun to include digital reports in the star rating, and NCQA actively encourages ECDS to submit specific HEDIS measures. Both organizations represent a shift to real-time, clinically rooted performance measurement – claims-based reporting is no longer sufficient.
Meaningful advances have not been made in the automation of electronic health record (EHR) integration, digital data exchange, and quality reporting risks that lag rapidly, meaning face opportunities such as delayed star reports, less favorable audit results, and missed opportunities to capture performance improvements in real time.
Investment platforms and partnerships allow you to collect, integrate and take clinical data, not just claims. Establish capabilities to support ECD reporting for HEDIS measures and prepare faster stellar computing cycles related to digital performance.
Double Health Equality – Don’t Wait 2027
Until 2027, outstanding health outcomes for everyone (formerly known as the Health Equity Index) will not affect ratings, but that doesn’t mean that plans should wait for action. Even as federal funding for diversity research and programs has been reduced, CMS is still measuring the differences among underserved populations.
CMS goes beyond basic demographics, which contain social determinants of health (SDOH), such as dual-pass status, low-income subsidies (LIS), disability and rural areas, which are not only used for tracking, but are key factors in adjusting star ratings and identifying performance-based incentives. This extends the equity lens to rural and urban communities and evaluates and rewards health programs based on their ability to reduce gaps and improve the outcomes of their highest risk members.
Enhance your ability to stratify quality and leverage data through demographic and social risk factors. Identify performance gaps in dual and LIS populations and use partners they meet to bridge these care gaps. If you have slowed down or paused your SDOH plans, it’s time to reignite them.
Position your long-term success plan
The 2025 CMS final rule provides a clear direction for health programs, namely the direction of quality measurement – a more simplified system, a more focused on health outcomes and an ongoing emphasis on equity. With growth forecasts that exceed expectations and reimbursement stability, plans can now take meaningful steps.
This is a great opportunity to align strategies with the evolving framework of CMS by refining care models to focus on impact, investing in digital capabilities that support data usage, and continuing to build infrastructure to address care differences.
By taking intentional action immediately, health plans can not only meet today’s expectations, but also prepare for a more integrated, result-centric system in the future.
Photo: Gustavofrazao, Getty Images
MPH, MBA, Dr. Liz Kwo, MD, is Chief Commercial Officer of Everly Health, a digital health company that expands opportunities for virtual leading disease prevention, diagnosis and treatment.
Previously, Dr. KWO served as Deputy Chief Clinical Officer of Elevance and founded several companies, including Infinitemd (by Consumer Healthcare) and New Pathway Education and Technology Group (by EIC Education). Dr. KWO sits on board members of Asensus surgery, Walmart Mexico, Central America, Bluewind Medical and Chronisense.
Dr. KWO is the author of Digital MD: The Future of Changing Healthcare and the host of Digital MD podcast. She is a practicing physician at Cambridge Health Alliance Hospital and a faculty member at Harvard Medical School. Dr. KWO is board certified in preventive health and occupational medicine and holds a bachelor’s degree in human biology from Stanford University, a MD from Harvard Medical School, an MBA from Harvard Business School, and an MPH from Harvard TH Chan School of Public Health.
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