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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 yr 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 think about incorporating novel incentive packages in these bids—incorporating ways confirmed to work in sufferers with well being complexities — to shut gaps in care and help sturdy Well being Fairness Index efficiency.
Happening offense for Star Score efficiency
Through the current “CMS Bid Bootcamp” hosted by RISE, conversations centered on sensible methods for navigating the MA cost panorama and on HEDIS (the Healthcare Effectiveness Knowledge 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 will likely be added for Measurement 12 months 2026 — Kidney Well being Analysis for Sufferers with Diabetes, Bettering or Sustaining Bodily Well being, and Bettering or Sustaining Psychological Well being — HEDIS triple-weighted measures embrace:
- Diabetes care — Blood Sugar Managed
- Medicines Adherence for Diabetes Medicines
- Medicines Adherence for Ldl cholesterol (Statins)
- Medicines Adherence for Hypertension (RAS Antagonists)
- Controlling Blood Strain
- Plan All-Trigger Readmissions
This emphasis on preventive care and persistent situation administration turns up stress on well being plans to undertake new approaches to member engagement and deal with care early and all through the plan yr. Low affected person participation and adherence to packages for persistent care, advanced care journeys, and wellness are main contributors to extreme healthcare prices and affect well being plans’ means to shut gaps in care. With no 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 the majority 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 yr 2027, placing high quality bonus funds in danger for high-performing Medicare Benefit plans. Many well being plans might lose tons of 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 inconceivable for plans to attain 5 stars.
Creating methods for 2026 plan success and past
Well being plans should earn a ranking of 4 stars or greater to obtain a 5% bonus, but the common plan ranking dropped to 4.04 in 2024, reducing 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 yr to reinforce 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 personalised, tailor-made outreach in empowering deprived sufferers to take management of their well being. In current well being plan pilots, for instance, such a mannequin has pushed a 178% enhance in major care visits, a 264% enhance 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 persistent 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 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 charge 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
- Larger 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 embrace this design of their 2026 bids. Use of omnichannel engagement, which a McKinsey & Firm survey signifies is most well-liked amongst Medicare Benefit beneficiaries, ought to complement this mannequin.
2. Apply a behavioral well being science-based method to member engagement. Participating Medicare members in initiatives designed to strengthen remedy adherence and self-management of persistent circumstances is notoriously troublesome. Not solely should program coordinators overcome layers of seeded mistrust to display the worth of member participation, however the on ramp for schooling, exercise monitoring and shutting essential gaps in care is commonly unnecessarily advanced. The truth is, app-based well being education schemes have a median dropout charge of fifty%, with many having charges as much as 80%.
That is an space the place behavioral economics could be a highly effective instrument for closing gaps in look after advanced populations and illness cohorts. As an illustration, one method 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 manner — “Right here’s what you’re going to get out of this service. Right here’s what we’re going to present 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 essential to make use of clear, direct language in making use of this method. By speaking transparently, you may assist lower by way of the barrier of distrust that comes from being handled marginally by establishments and methods. Speaking typically can 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 are linked to the Well being Fairness Index, similar to finishing screenings for breast most cancers annual flu pictures. Actions similar to these enhance the probabilities of receiving this reward in a yr when many plans usually are 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 fulfillment underneath an evolving measurement system. They’ll additionally apply these strategies to persistent situation administration outdoors the Star Rankings program. Such efforts place plans to extra successfully enhance well being outcomes and scale back prices.
Photograph: designer491, Getty Photographs
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 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 way of a grant from the Heart for Medicare & Medicaid Innovation. Via his work with Reciprocity Well being, Swanson works on the intersection of behavioral economics and healthcare, searching for to basically remodel the Medicaid and Medicare markets.
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