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 applications in these bids—incorporating ways confirmed to work in sufferers with well being complexities — to shut gaps in care and assist robust Well being Fairness Index efficiency.
Occurring offense for Star Score efficiency
In the course of the latest “CMS Bid Bootcamp” hosted by RISE, conversations targeted on sensible methods for navigating the MA cost panorama and on HEDIS (the Healthcare Effectiveness Information and Info Set). In Stars 12 months 2026, HEDIS will turn into the highest-weighted Star measure class, comprising 26% of a Medicare Benefit plan’s Star Score for 2027.
Along with three new measures that might 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
- Medicines Adherence for Diabetes Medicines
- Medicines Adherence for Ldl cholesterol (Statins)
- Medicines Adherence for Hypertension (RAS Antagonists)
- Controlling Blood Stress
- Plan All-Trigger Readmissions
This emphasis on preventive care and power situation administration turns up strain on well being plans to undertake new approaches to member engagement and tackle care early and all through the plan 12 months. Low affected person participation and adherence to applications for power care, advanced care journeys, and wellness are main contributors to extreme healthcare prices and influence well being plans’ means to shut gaps in care. And not using a plan for efficiently addressing the complexities of adherence, well being plans is not going to obtain the Well being Fairness Index reward issue.
Consultants venture that almost all well being plans is not going to 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 present 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 a whole lot of tens of millions of {dollars} in income if they don’t obtain this reward issue. Poor efficiency on this measure would additionally make it unimaginable for plans to realize 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, reducing from 4.14 in 2023 — and this downward slide doesn’t present indicators of rebounding. Demonstrating robust efficiency in 2026 — and positioning a well being plan to proceed to carry out effectively because the Star Score system evolves over time — will rely upon new, extremely modern approaches to member engagement grounded in science.
Listed here are three strategic actions well being plan leaders ought to prioritize this 12 months to reinforce 2026 bids to safe stronger Star Score efficiency.
1. Discover methods to include gamification in member engagement. New analysis factors to the ability of monetary incentives and personalised, tailor-made outreach in empowering deprived sufferers to take management of their well being. In latest well being plan pilots, for instance, such a 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 danger of decreased income and member satisfaction if plans battle to shut gaps in power care administration, it’s time to contemplate why gamification holds robust 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 customized, 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 price of comparable app-based instructional applications
- 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 bettering 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 strategy to member engagement. Participating Medicare members in initiatives designed to strengthen therapy adherence and self-management of power situations is notoriously tough. Not solely should program coordinators overcome layers of seeded mistrust to exhibit the worth of member participation, however the on ramp for training, exercise monitoring and shutting essential gaps in care is usually unnecessarily advanced. In reality, app-based well being teaching programs have a median dropout price of fifty%, with many having charges as much as 80%.
That is an space the place behavioral economics is usually a highly effective instrument for closing gaps in look after advanced populations and illness cohorts. As an example, one option 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 approach — “Right here’s what you’re going to get out of this service. Right here’s what we’re going to provide 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 advanced care journey and highlights the worth that members can anticipate.
It’s necessary to make use of clear, direct language in making use of this strategy. By speaking transparently, you’ll be able to assist reduce by means of the barrier of distrust that comes from being handled marginally by establishments and techniques. Speaking usually can be important. Take the time to elucidate 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. Provide 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 are linked to the Well being Fairness Index, equivalent to finishing screenings for breast most cancers annual flu pictures. Actions equivalent to these improve the possibilities of receiving this reward in a 12 months when many plans should 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 beneath an evolving measurement system. They will additionally apply these strategies to power situation administration outdoors the Star Rankings program. Such efforts place plans to extra successfully enhance well being outcomes and scale back prices.
Picture: designer491, Getty Photos
Matthew Swanson is CEO and co-founder of Reciprocity Well being, Inc., a managed service that strengthens care plan adherence by means of an all-digital engagement platform and reward applications designed to satisfy the wants of advanced care cohorts. Previously, Swanson served because the founding director and chairman of the Delaware Heart for Well being Innovation, a non-profit group devoted to the implementation of Delaware’s State Healthcare Innovation Plan and funded partly by means of a grant from the Heart for Medicare & Medicaid Innovation. By way of his work with Reciprocity Well being, Swanson works on the intersection of behavioral economics and healthcare, in search of to basically remodel the Medicaid and Medicare markets.
This put up seems by means of the MedCity Influencers program. Anybody can publish their perspective on enterprise and innovation in healthcare on MedCity Information by means of MedCity Influencers. Click on right here to learn how.