Rethinking HEDIS and Stars: Building a quality-first culture

HEDIS measures and Stars Ratings are central to how US health plans evaluate and incentivize care quality. They measure performance and create financial incentives that encourage proactive detection and management of conditions, while adding operational complexity for providers contracted with those plans.

However, these are not straightforward, check-the-box programs, and organizations often struggle to balance population health efforts while maintaining compliance and quality care. Here are some common challenges involved with launching HEDIS and Stars initiatives, along with practical strategies to shift from a compliance-driven mindset to a quality-first culture.

Shifting internal mindsets from compliance to quality culture

My former mentor once told me, "As long as you do what's right for the patient, the money will follow."

That advice still holds, but only if doing what’s right is paired with accurate documentation and coding. In value-based care, high performance depends not just on providing quality care but on capturing it in the data. When a service isn’t coded correctly or falls outside a measure’s timeframe, it won’t count, even if the care itself was excellent.

When compliance dictates actions that don't make sense or fail to account for the ramifications for your patients, that’s when you encounter problems. In those cases, organizations need to revisit how their processes serve both goals. It’s also essential to educate and simplify things for providers, as they might not be familiar with all the compliance requirements for every health plan and contract. It’s necessary to train the entire organization to understand why mammograms, colonoscopies, and other quality measures are essential and why we're asking them to implement them.

Building this shared understanding is essential, especially since Star Ratings bonuses go to health plans and only reach providers through their contractual arrangements. When clinicians see how these measures ultimately tie back to better patient care and organizational sustainability, compliance becomes a by-product of quality—not the other way around.

Addressing care gaps year-round

HEDIS, Stars, and other quality programs require an annual strategy. Gap closure should be designed for continuous, year-round data capture and real-time closure at the point of care, rather than end-of-year chart abstraction alone.

If a contract isn't performing or the assigned healthcare provider can’t reach all of their patients, you can bring in what I like to call a “striker team.” That team would be pulled off regular daily activities to help the provider be laser-focused. It could take a week or more, but all the information on all the patients would be sent to the payers.

That’s what I call short-term gap closure: periods when you need an all-hands-on-deck push to complete outreach or documentation before reporting deadlines. These surge efforts are valuable, but they also need to be balanced with sustained, long-term strategies for year-round gap management. Some gaps can be resolved through administrative workflows, like scheduling or record retrieval, while others require clinical review and judgment. The key is to clearly define which responsibilities belong to each team, so both administrative and clinical staff can work efficiently without overlap or burnout.

Streamlining contract complexities

When I first started getting involved in HEDIS and Stars, I had 15 different contracts. Every single one was completely different. I went from never having to report on any of it (because I wasn't in any value-based contracts) to needing to be aware of 70 other measures.

Eventually, I became savvy enough to learn that I could leverage my influence with payers. Even though the measures themselves are defined and scored outside your organization, you can still work with payers to focus your contracts on a common, manageable set that your infrastructure can reliably support. Aligning incentive sets this way helps reduce confusion, concentrate effort, and make meaningful improvement achievable across all agreements.

Normalizing data

Managing unwieldy healthcare data is a significant challenge in value-based care. We all know that data is often siloed across departments and in various formats. That’s why a centralized location at each provider group, where their data is normalized, is critical.

Organizations must either build their own data warehouses to store all this information internally or work with a third-party provider to manage it. If you can normalize your information and then serve it back to the various departments that need it, everybody will pull from the same central repository, allowing them to take action with all of this rich data. Keeping auditability in mind, make sure that all data feeding quality reporting is validated, traceable, and consistent across systems.

Engaging physicians through a patient-first approach

Ultimately, healthcare providers are more concerned with the clinical aspects of their work. They are committed to keeping their patients healthy. And until every single administrator adopts the mindset of doing what's right by patients, providers will view value-based care through programs like HEDIS and Stars as an administrative burden.

The goal isn’t to choose between quality and compliance, but to have them reinforce each other, using compliance measures to document and scale the quality care clinicians already provide. When organizations approach compliance this way, they can close care gaps more effectively, streamline contracts, and normalize data to make these programs run smoothly and successfully.

Dana McCalley, VP of Value-Based Care at Navina