When the 2025 Medicare Benefit Star Rankings have been introduced, solely 42% of plans with prescription drug protection scored 4 or 5 stars, down from 68% in 2022. This marks the third consecutive 12 months of decline of high-performance plans — turning up the warmth for Medicare Benefit (MA) plans to regulate their methods to guard efficiency.
Now, as well being plans put together their 2026 bids, leaders ought to take into account incorporating novel incentive packages in these bids—incorporating techniques confirmed to work in sufferers with well being complexities — to shut gaps in care and help sturdy Well being Fairness Index efficiency.
Occurring offense for Star Score efficiency
Throughout the current “CMS Bid Bootcamp” hosted by RISE, conversations targeted on sensible methods for navigating the MA fee panorama and on HEDIS (the Healthcare Effectiveness Information and Data Set). In Stars 12 months 2026, HEDIS will grow to be the highest-weighted Star measure class, comprising 26% of a Medicare Benefit plan’s Star Score for 2027.
Along with three new measures that will probably be added for Measurement 12 months 2026 — Kidney Well being Analysis for Sufferers with Diabetes, Enhancing or Sustaining Bodily Well being, and Enhancing or Sustaining Psychological Well being — HEDIS triple-weighted measures embody:
- Diabetes care — Blood Sugar Managed
- Drugs Adherence for Diabetes Drugs
- Drugs Adherence for Ldl cholesterol (Statins)
- Drugs Adherence for Hypertension (RAS Antagonists)
- Controlling Blood Strain
- Plan All-Trigger Readmissions
This emphasis on preventive care and continual situation administration turns up strain on well being plans to undertake new approaches to member engagement and deal with care early and all through the plan 12 months. Low affected person participation and adherence to packages for continual care, complicated care journeys, and wellness are main contributors to extreme healthcare prices and influence well being plans’ capability to shut gaps in care. With no plan for efficiently addressing the complexities of adherence, well being plans won’t obtain the Well being Fairness Index reward issue.
Specialists undertaking that the majority well being plans won’t obtain the Well being Fairness Index reward issue, which rewards plans for lowering disparities in care amongst members with social threat elements. The Well being Fairness Index replaces the prevailing reward issue for Star Rankings 12 months 2027, placing high quality bonus funds in danger for high-performing Medicare Benefit plans. Many well being plans may lose tons of of hundreds of thousands of {dollars} in income if they don’t obtain this reward issue. Poor efficiency on this measure would additionally make it unattainable for plans to attain 5 stars.
Creating methods for 2026 plan success and past
Well being plans should earn a score of 4 stars or greater to obtain a 5% bonus, but the common plan score dropped to 4.04 in 2024, lowering from 4.14 in 2023 — and this downward slide doesn’t present indicators of rebounding. Demonstrating sturdy efficiency in 2026 — and positioning a well being plan to proceed to carry out properly because the Star Score system evolves over time — will rely upon new, extremely progressive approaches to member engagement grounded in science.
Listed here are three strategic actions well being plan leaders ought to prioritize this 12 months to boost 2026 bids to safe stronger Star Score efficiency.
1. Discover methods to include gamification in member engagement. New analysis factors to the facility of monetary incentives and customized, tailor-made outreach in empowering deprived sufferers to take management of their well being. In current well being plan pilots, for instance, any such mannequin has pushed a 178% improve in main care visits, a 264% improve in cervical most cancers screenings, and a return on funding exceeding 700%. For Medicare Benefit plan leaders, who face the chance of decreased income and member satisfaction if plans battle to shut gaps in continual care administration, it’s time to think about why gamification holds sturdy enchantment for deprived sufferers.
In West Virginia, for instance, a partnership between a managed care group, federally certified well being facilities, and a digital engagement specialist drove higher well being outcomes for high-risk, low-engagement members in a big well being plan. Key to success: a personalised, omnichannel member engagement designed with the wants and preferences of this inhabitants in thoughts — together with in partnership with organizations that have already got established relationships with these sufferers. For sufferers with Kind 2 diabetes, this resulted in:
- 74% completion of diabetes self-management program actions — a 48% enchancment over the median adherence fee of comparable app-based instructional packages
- Important reductions in A1c ranges (10.5% to eight.5%, p<.001), weight (250 to 239 kilos; p<.001) and BMI (41 to 37 kg/m2; p<.001) all through a 12-week program
- Increased charges of dedication towards higher well being, with 84% saying their motivation for enhancing outcomes had elevated
By assessing the teachings discovered in initiatives like this, Medicare Benefit plan leaders can develop their very own gamification mannequin and embody this design of their 2026 bids. Use of omnichannel engagement, which a McKinsey & Firm survey signifies is most popular amongst Medicare Benefit beneficiaries, ought to complement this mannequin.
2. Apply a behavioral well being science-based method to member engagement. Partaking Medicare members in initiatives designed to strengthen remedy adherence and self-management of continual circumstances is notoriously troublesome. Not solely should program coordinators overcome layers of seeded mistrust to exhibit the worth of member participation, however the on ramp for schooling, exercise monitoring and shutting crucial gaps in care is usually unnecessarily complicated. Actually, app-based well being education schemes have a median dropout fee of fifty%, with many having charges as much as 80%.
That is an space the place behavioral economics is usually a highly effective software for closing gaps in look after complicated populations and illness cohorts. For example, one technique to set up belief amongst folks for whom the healthcare system has left them feeling disempowered is by framing a dialog round wholesome behaviors in a reciprocal means — “Right here’s what you’re going to get out of this service. Right here’s what we’re going to offer you that will help you enhance your well being.” This makes the “ask” very clear from the beginning. It additionally establishes belief, confidence and momentum for folks to proceed making strides on their complicated care journey and highlights the worth that members can count on.
It’s vital to make use of clear, direct language in making use of this method. By speaking transparently, you may assist minimize by way of the barrier of distrust that comes from being handled marginally by establishments and methods. Speaking typically can also be important. Take the time to clarify how a advantages program or incentive works—and accomplish that as a lot as wanted.
3. Use rewards to drive member engagement with Well being Fairness Index measures. Supply incentives for members to finish social threat issue surveys, sharing info round revenue, race and ethnicity, sexual orientation and extra. Search for methods, too, to reward members for finishing actions inside their care plan which can be linked to the Well being Fairness Index, similar to finishing screenings for breast most cancers annual flu pictures. Actions similar to these improve the possibilities of receiving this reward in a 12 months when many plans are usually not anticipated to take action.
By exploring these behavioral science-based, incentive-driven approaches to member engagement, Medicare Benefit plans can extra successfully place themselves up for achievement underneath an evolving measurement system. They’ll additionally apply these methods to continual situation administration exterior the Star Rankings program. Such efforts place plans to extra successfully enhance well being outcomes and cut back prices.
Photograph: designer491, Getty Pictures
Matthew Swanson is CEO and co-founder of Reciprocity Well being, Inc., a managed service that strengthens care plan adherence by way of an all-digital engagement platform and reward packages designed to satisfy the wants of complicated care cohorts. Previously, Swanson served because the founding director and chairman of the Delaware Middle for Well being Innovation, a non-profit group devoted to the implementation of Delaware’s State Healthcare Innovation Plan and funded partially by way of a grant from the Middle for Medicare & Medicaid Innovation. By his work with Reciprocity Well being, Swanson works on the intersection of behavioral economics and healthcare, in search of to essentially remodel the Medicaid and Medicare markets.
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