Wednesday at The 16th Annual HEDIS® & Quality Improvement Summit in Baltimore opened with two big-picture sessions. NCQA's keynote laid out the 10 measures retiring in MY 2027, the new person-centered outcome measures and the ECDS gains behind the digital transition, and former CMS official Mark Newsom followed with what the new Congress and the Clover ruling mean for Star Ratings.
The rest of the day focused on how to make quality run in a digital, multi-line, outcomes-focused environment. Here are five takeaways from the late morning and afternoon sessions.
1. The provider contract is becoming a quality strategy
With the hybrid method on track to leave HEDIS® by MY 2029, end-of-year chart review will no longer rescue a rate, and numerator data has to arrive from providers in structured form all year. Most provider contracts were written for the old model, with HEDIS® duties spread across the participation agreement, regulatory addenda, the provider manual and incentive amendments, and with terms like "timely" and "cooperate" left undefined.
Moving gap closure to providers does not move accountability, since federal rules keep data completeness and quality reporting with the plan. Sessions pointed to the incentive amendment as the place where data terms carry the most weight, and to the CMS Provider Access API, due January 1, 2027, as new leverage. Once plans share claims and clinical data with providers by law, asking for structured data back by contract becomes a two-way exchange rather than a one-way records request.
2. Check the data before you pick up the phone
The members with the most open gaps are often the hardest to reach, and every unnecessary call, letter or text adds to outreach fatigue. Several sessions made the case for searching registries, HIEs, lab feeds and provider data before any outreach, recording a closed gap as supplemental data and removing the member from the outreach list, then bundling all remaining gaps into one coordinated contact.
Format matters as much as the source. A screen recorded in free text or a scanned document scores as never done under ECDS, and codes outside the HEDIS® Value Set Directory leave rates underreported. Plans running Medicaid, Marketplace and MA side by side also heard a case for organizing by measure rather than product line, with one owner, one gap list and one data pipeline per measure across every scorecard a member touches.
3. Aggregate rates hide the gaps, and closing them moves the overall rate
An overall rate is a weighted average, so a large, well-performing majority absorbs a smaller subgroup falling behind. Stratifying rates by race, ethnicity, language and geography shows where members fall out, and the largest gains per member sit where performance is lowest and volume is meaningful. Stratified results depend on reliable demographic data, so completeness targets and a named owner came up as prerequisites.
Depression Screening and Follow-Up (DSF-E) was the clearest example. MY 2027 is the first measurement year counting toward Star Ratings, with results flowing into the 2029 Stars, so screening workflows, follow-up capacity and structured capture need to be running before January. Research presented at the Summit showed screening rates rising while follow-up after a positive screen lagged, which points budgets toward follow-up capacity. On the diabetes side, Glycemic Status Assessment (GSD) results separate members who were never tested from members who were tested and remain uncontrolled, and the two groups need different work. Because A1c reflects roughly three months of history, interventions launched midyear often show up in next year's rate.
4. The value case lives beyond the numerator
Case studies on the agenda tied gap closure to utilization and cost, giving quality teams a stronger business case than numerator compliance alone. A Medicaid behavioral health program pairing follow-up after mental health hospitalization with barrier screening and care navigation reported a 10.4 percent drop in total cost of care for engaged members and $4.57 in annual value for every $1 invested. A Medicare Advantage heart failure program built on pharmacist-led medication conversations reported medication adherence of 90.6 percent, hospital admissions down 39.5 percent, ER visits down 15.6 percent and a 5:1 return over 12 months.
Both programs built their analysis in from the start, using comparison groups and pre- and post-intervention claims, so the results held up when leadership asked whether the money moved anything.
5. Most barriers show up between visits
Members in these programs often had coverage, providers and access to care, and still did not complete the visit, refill or follow-up. Conversations surfaced the reasons, including transportation, medication costs and side effects, complex regimens, social isolation and confusion about the condition itself.
Asking why a member stopped a medication produced more useful answers than asking whether the member took the medication.
Sessions also pointed to the visit itself as an opportunity. Combining risk adjustment and quality in one encounter, bringing labs and screenings into the workflow, meeting members at trusted locations and following up with care coordination after the visit all reduce the number of times a member has to show up, and the coordination record gives the plan evidence of treatment.
Quality data, Stars program changes and the math behind cut points anchor The RISE Star Ratings Master Class, December 14-16 at the Fairmont Scottsdale Princess in Scottsdale, Arizona, including the Quality Data Deep Dive and Cutpoint Hackathon workshops.
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