2026 Quality Execution Pivot: Measures to Meaningful Action

For the last three years, health plans have operated in a “member experience” world. Driven by the heavy 4x weighting of CAHPS, the strategy was simple: keep members happy, and the Stars would follow.

As we enter 2026, however, the winds have shifted. CMS and NCQA haven’t just moved the goalposts — they’ve changed the game entirely. The retrospective, end-of-year reporting models of the past have evolved from a standard process into a primary source of financial and compliance risk.

Health plans are now facing a triple threat to the traditional quality operating model.

1. Great re-weighting: The “member experience” era has officially downshifted. According to the CMS 2026 Star Ratings Fact Sheet, CAHPS weighting has dropped from 4x to 2x. In its place, clinical outcomes and Quality Improvement (QI) measures — now carrying a significant 5x weight — have re-emerged as the true kingmakers of Star Ratings and the 5% Quality Bonus Payment (QBP).
   
2. The Reward Factor Reset: In another major shift, the CY 2027 Proposed Rule signals the removal of the Health Equity Index (HEI) and Excellent Health Outcomes (EHO) rewards, reverting instead to the historical Reward Factor methodology.
   This fundamentally changes the goalpost - from optimizing performance in select cohorts to maintaining consistently high performance across the entire measure set. Under this model, one or two underperforming measures can effectively “zero out” reward eligibility, regardless of strong performance elsewhere.
3. The dQM Transition: NCQA’s HEDIS MY 2026 update introduces six new ECDS measures and transitions three additional measures to ECDS-only reporting. This move toward Digital Quality Measures (dQMs) transforms quality into a 365-day data integrity challenge.
   The traditional “chart chase” is being replaced by continuous clinical data exchange, requiring real-time, interoperable workflows rather than seasonal clean-up efforts.

The Execution Gap: Why Strategy and Analytics Aren’t Enough

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Most health plans don’t suffer from a lack of strategy or analytics. They suffer from an execution gap.

It’s a familiar cycle: gaps are identified in April, but clinical outreach doesn’t meaningfully begin until October. By then, the data is stale, providers are frustrated, and revenue risk is already baked in.

Closing this gap requires moving away from fragmented point solutions and toward a truly integrated quality execution platform.

The Modern Quality Operating Model

To survive — and succeed — in this new environment, the quality operating model must function as a closed loop.

ZeOmega’s Jiva platform acts as the nervous system for this new era, connecting quality intelligence directly to the point of care through three core pillars.

1. Intelligence Orchestration (Care Quality Navigator - CQN)
   In the Reward Factor era, a single weak link can derail the entire measure set. With QI measures now weighted at 5x and reward eligibility hinging on consistent performance, every gap matters.
   CQN operationalizes analytics by prioritizing workflows in real time — ensuring limited care-team capacity is focused on the members who drive both improvement scores and overall contract distribution.
2. Purposeful Engagement (Member Engagement Navigator - MEN)
   With CAHPS weights reduced, engagement must shift from high-volume outreach to high-value interaction. MEN ensures that every digital nudge — whether SMS, portal alert, or notification — is directly tied to a specific clinical outcome.
   The result is meaningful gap closure without compromising a frictionless member experience.
3. Social Barrier Mitigation (SDOH Social Care Platform & Social Care Connect)
   Under NCQA SNS-E (Social Need Screening and Intervention) requirements, identifying a social need is no longer sufficient. HEDIS credit now requires evidence of a closed-loop intervention.
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   Jiva supports this through two complementary tiers:
   • SDOH Social Care Platform
     Bridges the gap between clinical insight and social action by integrating seamlessly with third-party referral platforms.
   • Social Care Connect (SCC)
     Designed for plans moving from referrals to results, SCC is a dedicated closed-loop referral system that brings Community-Based Organizations (CBOs) directly into the Jiva ecosystem, —enabling real-time creation, assignment, and tracking of social care referrals.

The 2026 ROI: Beyond the Scorecard

Shifting from measuring quality to running quality delivers immediate and tangible returns:

• Revenue Protection
  Maximizing the 5x QI lever to secure the 5% Quality Bonus Payment.
• Audit Readiness
  Eliminating “January panic” through year-round, FHIR^® -ready evidence capture.
• Provider Alignment
  Delivering real-time, actionable insights instead of 60-day-old spreadsheets.

The question for leadership is no longer “What is our score?”
It is now: “Do we have the right platform to improve that score in real time?”

References:

^{https://www.cms.gov/medicare/quality/cms-national-quality-strategy/meaningful-measures-20-moving-measure-reduction-modernization}

^{https://www.ncqa.org/blog/social-need-screening-and-intervention-whats-changing/}

^{https://www.ncqa.org/hedis/the-future-of-hedis/}

^{https://www.ncqa.org/blog/hedis-my-2026-whats-new-whats-changed-whats-retired/}

^{https://www.cms.gov/newsroom/fact-sheets/contract-year-2027-medicare-advantage-part-d-proposed-rule}

^{https://www.cms.gov/files/document/2026-star-ratings-fact-sheet.pdf}