Why the STARs Are Falling & How to Course-Correct: Transitioning to Digital HEDIS®

This year NCQA announced the official phased transition to Digital HEDIS® measures by 2030. The move to Digital HEDIS transforms quality reporting into a proactive, data-driven process, giving organizations more visibility and control over their ratings throughout the measurement year. 2030 may seem far away, but there are tremendous benefits to early adoption.

As NCQA and CMS accelerate the push toward data modernization and introduce more rigorous quality measures, Payers may experience challenges ahead. But every challenge brings an opportunity for optimization. Let’s explore the main pressures on Star Ratings, how successful plans are course-correcting today, and Smile’s pivotal role in a well-transitioned implementation.

Key Pressures on Star Ratings

Changes in CMS Methodology

CMS has steadily tightened the thresholds plans must meet to achieve high scores. One significant change is the strategic reduction in the weight of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys, which many Payers historically relied on to maintain higher ratings. With this change in methodology, extremely low-performing outliers that previously skewed benchmarks downward, causing an upward shift in cut point are removed, making it harder to achieve 5-star ratings. This change will increase reliance on clinical and operational performance as early as measurement year 2026.

Beginning with the 2024 Star Ratings, CMS also removed low-performing outliers that previously lowered benchmarks. This methodological shift has raised performance thresholds, making 5-star ratings harder to attain, even with safeguards against abrupt increases.

Falling Behind on Modern Approaches

Many Payers continue to rely on traditional claims-based models for quality submissions. This outdated model is making it increasingly insufficient to comply with modern data requirements. According to J.D. Power’s 2025 Healthcare Digital Experience Study, health plans’ digital interfaces lag behind other industries, negatively impacting member satisfaction and renewal intent.

Reduction in CAHPS weighting and reliance on traditional, hybrid reporting approaches leave plans vulnerable to rating declines, even if their underlying clinical quality performance is stable.

The Provider-Payer Disconnect

A key contributor to declining scores is the systemic misalignment between Payers and Providers:

• Manual, retrospective reporting creates administrative burden and delays,
• Providers are not directly accountable for HEDIS® Scores or STAR Ratings, limiting engagement,
• A lack of real-time visibility into care gap closure and managing risks for Payers.

Pain points include:

• Dependency on time-consuming chart reviews (chart-chasing) that are often incomplete,
• Delayed claims that miss real-time risk detection and intervention opportunities,
• Retrospective measurement cycles (up to 18 months later) that prevent proactive gap closure.
• Audit anxiety fueled by poor data lineage and incomplete or missing documentation.
  
  

The Smile Commitment: Bridging the Gap with Digital Quality Measures

As the first and only NCQA-validated vendor for Digital HEDIS, Smile Digital Health accelerates both compliance and competitive advantage. Smile provides Payers and Providers organizations with technology and implementation solutions designed to improve collaboration and enhance quality measurement. Here’s how:

• Our FHIR®-native, EHR-agnostic single source-of-truth repository sits between EHRs and Payers as a neutral, digital foundation for modern, value-based care alignment. 
• CMS data priorities are addressed with enhanced numerator capture from structured clinical data, not just claims (ingesting and normalizing data from EHRs, HIEs, and registries).
• Integration with EHRs and care management tools to deliver clinical decision support alerts, and care gap notifications.
• Real-time care gap detection and proactive intervention powered by our FHIR & CQL engine.
• Full support for provenance, auditability, and use of standardized terminologies (LOINC, SNOMED, CVX), reducing audit risk and building trust in your data.
• Prospective measurement capabilities that predict members at risk of falling out of compliance, enabling in-year course correction.
• FHIR-based care gap APIs that facilitate seamless data sharing and alignment with both STAR and HEDIS logic across Payer and Provider systems.
• Analytics to surface missing or under-reported data and identify opportunities for preemptive care gap closure.
• Provider-facing tools that illuminate the clinical impact of care decisions in real time.

The Bottom Line

STAR Ratings may be falling, but with the right digital-first strategies and trusted partnerships, Payers can regain momentum. The shift to Digital HEDIS and modern interoperability standards isn’t a hurdle; it’s an opportunity to optimize quality, strengthen provider relationships, and improve member outcomes, all while positioning your business for future success in an evolving digital health delivery landscape.