HEDIS and Stars Quality Measure Improvement

Medicare Advantage health plans with direct Stars financial exposure know, months before the measurement window closes, which members are holding down specific measure scores. A member who has not had a glycosylated hemoglobin test in the measurement year is an open HEDIS CDC measure. A member who has not filled their statin for three consecutive months is an open Medication Adherence measure. The member is identified. The financial impact of non-completion is calculated. The window is still open.

The challenge is that knowing a measure is open is different from having the infrastructure to close it. Sending a letter that tells a member a test is due results in low response rates — not because members do not care about their health, but because a letter does not schedule the appointment, does not identify the reason the test has not been completed, and does not navigate the specific barrier that kept the member from completing it in the first place. The member who has not had their colorectal cancer screening has a reason. Cost, access, fear, previous negative experience, logistics. That reason does not appear in the claims data, and a generic outreach does not address it.

For health plans where Stars ratings drive plan revenue, per-member-per-month payments, and CMS bonus pools, HEDIS measure performance is a financial performance lever that affects the plan's margin materially. A plan that moves from three to four stars generates meaningfully higher revenue per member. The plan that knows which members and which measures represent the gap between those ratings — and still cannot close them before the measurement window ends — is leaving a known financial opportunity uncaptured.

Your quality team chooses the measures and approves the scripts. Care managers take anything clinical.

Open measures, ranked. Members with open measures are ranked by measure and by the time left in the measurement year.

A two-way conversation. The agent explains the measure in plain language, asks what is in the way and offers options.

The service is booked. Labs, screenings and visits are booked at a place and time that work for the member, with reminders before them.

Barriers and questions go to people. Cost, transportation and clinical questions are routed to a care manager or member services by rule.

Closure tracked by measure. The quality team sees open, booked and completed items by measure and week.

Agents escalate, clinicians decide. Agents follow the escalation rules your team sets and hand clinical questions to a licensed clinician. They don’t diagnose or recommend treatment.