Quality Improvement: Trending and Forecasting Your Bonus Performance

Understanding the Stars Framework

Introduced in 2007, the CMS Star Rating system evaluates plans on a scale of 1 to 5 stars across multiple domains, including:
 

• Clinical outcomes
   

• Patient experience
   

• Access and complaints
   

• Drug adherence and safety
   

• Improvement over time

Plans that achieve 4 stars or higher qualify for QBPs, which significantly impact revenue and member benefits. Understanding this framework is the foundation for strategic planning and performance. 

Why Trending and Forecasting Matter More Than Ever

Recent years, the Star Ratings Program has observed volatile shifts in the Star Ratings driven by
 

• Methodology changes
   

• Weighting adjustments
   

• Introduction of Excellent Health Outcomes for All (EHO4All)
   

These changes make year-over-year trending and predictive forecasting more critical than ever. Plans must not only anticipate how current performance will translate into future ratings but also respond proactively to emerging trends.

Key Trends Impacting Star Performance

Despite a slight increase in overall ratings for 2026, the trend in ratings has decreased significantly since 2022. The percentage of contracts earning a 4 star or higher continues to drop. Industry-wide performance caused shifts in cut points meaning that if the cut point increased, the bar was raised due to better performance. For example, if the cut point for controlling high blood pressure moved from 85% to 88%, that signifies that health plans must perform better to maintain the same star level. 

Tukey Outlier Deletion also impacts Star performance because it removes extreme scores that could skew the cut points. Outlier scores tend to be on the low end of the distribution, so removing them shifts the cut points higher.  

Replacing the Reward Factor with EHO4All could have significant impact on plans that counted on their consistently high and stable performance to bring them into 4+ Star territory. To earn an increase in score under EHO4All, a plan must have higher performance than their peers for members with social risk factors. EHO4All has many stipulations that make it difficult to earn a score increase.
 

Larger, established plans tend to have an advantage in earning 4+ Star ratings, as their size can make it easier to score well on certain measures. For example, if a small plan with few appeals misses one appeal, achieving a 4 or 5 Star for the measure may not be possible. Conversely, a larger plan with a higher volume of appeals can afford to miss several appeals and still maintain a high score. Additionally, measures that don’t meet minimum requirements for denominator size and timing are excluded in the Star rating calculations. If not enough measures are rated, the plan will not be eligible for an Improvement score increase further impacting its overall score.

Forecasting Strategies for Stars Success

To stay ahead, plans should adopt the following forecasting strategies:

1. Model Cut Point Scenarios: Do not rely on last year’s published cut points. Instead, build multiple scenarios to model potential Star Ratings based on varying performance levels. This helps anticipate upward movement and prepare accordingly. 

2. Track Measure Evolution: New measures often experience rapid cut point movement in their first three years, especially when CMS does not apply guardrails. Use display measure data to forecast performance and allocate resources early. 

3. Monitor Weight Changes: All measures enter the program with a weight of 1. Over time, some increase in weight depending on their category. Measures with tight cut points may require near-performance performance to earn 4 or 5 stars. 

4. Prioritize Year-over-Year Improvement: Don’t underestimate the importance of improving performance year over year. The Part C and Part D Improvement measures are the highest weighted measures in the Star Ratings Program with a weight of 5. Increasing one of these measures by one star has the same effect as improving five measures with a weight of 1 by one star. 

Looking ahead: Preparing for Star Year 2026 and Beyond

Changes are made to the Star Ratings program each year as CMS priorities evolve. 
 

In Star Year 2026, here’s what is coming:
 

• Colorectal Cancer Screening transitions to Electronic Clinical Data System (ECDS)-only reporting 
   

• Health Outcome Survey (HOS) Improvement measures return (Improving or Maintaining Physical Health and Mental Health) with a weight of 1

• Outcome and Intermediate Outcome measures have a weight of 3
   

• The Patient Experience & Access measures drop from a weight of 4 to 2, creating a more even distribution of weight between the Star measure categories
   

For Star Year 2027, health plans can expect:
 

• HOS Improvement measures increase from a weight of 1 to a weight of 3. Plans should prioritize HOS strategies now
   

• New Measures Introduced: Concurrent Use of Opioids and Benzodiazepines, Polypharmacy Use for Multiple Anticholinergics, Care for Older Adults (COA) Functional Status Assessment
   

• Colorectal Cancer Screening expands to include ages 46-49 
   

• Statin Use in Persons with Diabetes includes a statin intolerance exclusion
   

• Eye Exam for Diabetes moves to admin only, removing the hybrid option
   

• Hybrid reporting for all HEDIS® measures sunsetting by 2030. Plans should prepare for this full transition to ECDS

Conclusion: The Path to 5 Stars Starts Today

Trending and forecasting Stars performance is a strategic imperative. Leveraging data, aligning organizational priorities, and preparing for regulatory shifts will allow health plans to both secure quality bonus payments and more importantly deliver a positive care journey for members. 

Make Star performance a priority. The path to 5 stars and a stronger member healthcare experience starts today.