The Centers for Medicare and Medicaid Services (CMS) Final Rule impacting Star Ratings shows a clear shift in priorities to focus on health outcomes and equity, where success is defined less by process and more by impact. Plans that act now to modernize and level-up their care models will be far better positioned to thrive in the evolving Stars landscape.
Here is what health plans need to prioritize in their current and future strategies.
Redesign care around outcomes — not checklists
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While operational metrics have been part of Stars, CMS has steadily expanded its focus on clinical outcomes, now pushing plans to move beyond process to impact. Plans need to reassess their current quality strategies and move beyond metrics that “check the box” to focus on initiatives that close care gaps and drive real health impact.
The National Committee for Quality Assurance (NCQA) recently updated its colorectal cancer screening measure to include follow-up colonoscopy following an abnormal stool-based test. This an important move from simply tracking who was screened to determine if appropriate diagnostic follow-up took place. While this measure isn’t yet part of the CMS Star Ratings program, it aligns with the direction CMS Star Rating measurements is headed: focusing on closed care loops and meaningful outcomes. As CMS aligns more closely with NCQA’s guidance, I expect similar evolutions to influence future Star Ratings. These kinds of changes aren’t just technical — they have the potential to save lives.
Reassess your Stars-related programs through the lens of outcomes. Are you tracking follow-ups after screenings? If not, it’s time to rethink both your data models and care workflows. Even more, focus on core clinical areas like diabetes, hypertension, and kidney disease, and improve care coordination for members with multiple conditions.
Make digital quality infrastructure a priority
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The expansion of Electronic Clinical Data Systems (ECDS) and API-based reporting is becoming a strategic imperative. CMS is beginning to incorporate digital reporting into Star Ratings, and NCQA is actively encouraging ECDS submissions for specific HEDIS measures. Both organizations are signaling a shift toward real-time, clinically grounded performance measurement—meaning claims-based reporting alone will no longer be enough.
Plans that haven’t made meaningful progress toward electronic health record (EHR) integration, digital data exchange, and automation of quality reporting risk falling behind quickly, which means facing challenges like delayed Stars reporting, less favorable audit outcomes, and missed opportunities to capture performance improvements in real time.
Invest in platforms and partnerships that allow you to collect, integrate, and act on clinical data, not just claims. Build capabilities to support ECDS reporting across HEDIS measures, and prepare for faster Stars calculation cycles tied to digital performance.
Double down on health equity — don’t wait for 2027
The Excellent Health Outcomes for All (formerly known as the Health Equity Index) won’t impact ratings until 2027, but that doesn’t mean plans should wait to act. Even as federal funding for diversity research and programs is being scaled back, CMS is staying the course on measuring disparities across underserved populations.
CMS is moving beyond basic demographics, incorporating social determinants of health (SDOH) such as dual eligible status, low-income subsidy (LIS), disability, and rurality — not just for tracking, but as key factors in adjusting Star Ratings and determining performance-based incentives. This extends the equity lens to both rural and urban communities, reinforcing that health plans will be evaluated and rewarded based on their ability to reduce disparities and improve outcomes for their most at-risk members.
Strengthen your ability to stratify quality and utilization data by demographic and social risk factors. Identify performance gaps across your dual and LIS populations, and engage partners who meet them where they are to close these care gaps. If you’ve slowed or paused SDOH initiatives, now is the time to reignite them.
Position your plan for long-term success
The 2025 CMS Final Rule offers health plans a clear direction of where quality measurement is headed — more streamlined systems, greater focus on health outcomes, and a sustained emphasis on equity. With higher-than-expected growth projections and reimbursement stability, plans are in a strong position to take meaningful steps forward now.
This is a great opportunity to align your strategies with CMS’s evolving framework by refining care models to focus on impact, investing in digital capabilities that support data use, and continuing to build infrastructure that addresses disparities in care.
By taking deliberate action now, health plans can not only meet today’s expectations but also prepare thoughtfully for the more integrated, outcome-focused system that lies ahead.
Photo: gustavofrazao, Getty Images
Dr. Liz Kwo, MD, MBA, MPH, is Chief Commercial Officer at Everly Health Solutions, a digital health company expanding access to virtual-first disease prevention, diagnosis, and treatment.
Previously, Dr. Kwo served as Deputy Chief Clinical Officer for Elevance, and has founded several companies, including InfiniteMD (acquired by Consumer Medical) and New Pathway Education and Technology Group (acquired by EIC Education). Dr. Kwo sits on the Board of Directors for Asensus Surgical, Walmart Mexico, Central America, BlueWind Medical, and ChroniSense.
Dr. Kwo is the author of Digital MD: Revolutionizing the Future of Healthcare and host of DigitalMD Podcast. She is a practicing physician at Cambridge Health Alliance Hospital and faculty lecturer at Harvard Medical School. Dr. Kwo is board-certified in Preventive Care and Occupational Medicine and holds a BA in Human Biology from Stanford University, MD from Harvard Medical School, MBA from Harvard Business School, and MPH from Harvard T.H. Chan School of Public Health.
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