The Shift in Star Ratings That Health Plans Can't Ignore

If you’re still using claims data to manage care, you’re already too late. When critical information about discharges, medication changes, or ED visits arrives weeks after a critical health inflection point, care managers lose the opportunity to act when it matters most. You're managing complications instead of preventing them.

The greatest opportunity

Transitions of care are where coordination most frequently breaks down — and where health plans have the greatest opportunity to influence outcomes across multiple quality measures.

Effective postdischarge coordination creates a compounding impact: better medication adherence, closed chronic care gaps, stronger member engagement that breaks recurring utilization patterns. One operational improvement, multiple measure impacts.

The challenge is timing. Members are most open to behavior change immediately following a care event. That brief window of impact demands systems that trigger action in real time.

What forward-thinking plans are building

Leading plans are shrinking the gap between clinical events and coordinated response by:

Deploying real-time encounter alerts that notify care teams immediately when a member is discharged from a hospital or emergency room visit, enabling intervention during the critical window when patients are most receptive to behavior change.

• Building interoperable systems that enable clinical data exchange across hospitals, primary care physicians, postacute providers and payers, ensuring care coordinators have the information they need to act, not days later when claims cycle through.
• Targeting high-impact measures like Transitions of Care (TRC), Medication Reconciliation Post-Discharge (MRP), and Plan All-Cause Readmissions (PCR) — a now triple-weighted measure—where real-time coordination delivers direct and measurable impact on Star Ratings performance.

Plans that invest in real-time visibility, clinical data exchange, and workflows built around proactive action will protect their Star Ratings and the revenue that depends on them. CMS is making its priorities clear: clinical outcomes matter more than ever, and the plans that can act fast during critical care transitions are winning.

In an increasingly competitive landscape where the gap between 4-star and 3.5-star performance can mean tens of millions in lost income, operational plans that invest in real-time coordination capabilities will protect their ratings and the revenue that depends on them. Operational speed isn't optional, it's essential.

Whitney Eubanks, M.S., is vice president of product management for PointClickCare.