Quality Measurement in Healthcare Today
Health plans are under pressure to elevate quality scores and deliver better outcomes. Metrics like the Healthcare Effectiveness Data and Information Set (HEDIS®) scores and CMS Star Ratings play a critical role in evaluating quality, driving financial incentives, and influencing member retention.
The data tells an important story, while over 90% of U.S. health plans use HEDIS measures and Medicare Advantage now covers about 34 million people, fewer plans are achieving high-quality scores. In 2025, only 40% of plans reached four stars or higher, down from 42% in 2024. This means just 62% of Medicare Advantage members are in high-quality plans, compared to 74% last year.
These numbers matter because they represent real people potentially receiving lower quality care and billions in missed revenue opportunities for health plans. The trend highlights the critical need for health plans to take better approaches to improving their quality scores and ensuring their members receive the highest level of care. Yet, despite their best efforts, many health plans struggle with fragmented outreach, outdated member data, and an inability to engage members in their care journeys effectively.
Leveraging technology is the key to enhancing member engagement strategies. Let’s explore why engagement matters and how targeted tools can make a measurable impact.
Why Member Engagement Matters for Quality Scores
HEDIS scores and Star Ratings serve as benchmarks for healthcare quality, influencing everything from employer selection of health plans to value-based reimbursement models. However, improving these scores requires more than just administrative oversight. It demands a proactive approach to member engagement.
The old way of doing things — disconnected outreach efforts, outdated member contact information, and reactive approaches — simply doesn't work anymore. We need to flip the script: engage members and drive quality improvements. Not the other way around.
Benefits of Effective Member Engagement
There are numerous reasons to enhance member engagement, including:
- Closing care gaps through better outreach and preventive screenings.
- Enhancing the member experience measures, such as CAHPS survey scores.
- Reducing hospital readmissions by addressing social determinants of health (SDOH).
- Improving adherence to care plans and medication regimens.
- Empowering members with self-help tools like ID card requests, PCP changes, and demographic updates to encourage proactive engagement.
In an era where clinical expectations align more with consumer experiences, members expect their health plans to deliver timely, personalized, and convenient interactions. The right engagement strategy can be a game-changer.
Toolkit to Boost Quality Through Better Member Engagement
The following steps paint a clear pathway to better member engagement, which ultimately leads to improved health.
1. Use Data to Close Care Gaps
Outdated member information is a huge problem for health plans. Contact data gets worse every month as people change addresses, phone numbers, and sometimes even names. This means many outreach efforts never reach their intended audience.
We also do not often have data on which type of outreach has been successful in the past. Tracking what a particular member responds to, whether it is SMS text, email, phone calls, or a knock on the door, would help us understand how to create engagement strategies that work in the future.
Take diabetes management, for example. One key HEDIS measure, Hemoglobin A1c (HbA1c) control for people with diabetes, tracks whether members maintain blood sugar levels within a healthy range. Behind this seemingly simple metric is a complex challenge: How do you effectively reach eligible members, address their concerns about diabetes management, and help them schedule necessary tests?
The Jiva Care Quality Navigator (CQN) provides health plans with a powerful tool to identify and address care gaps, track provider performance, and enhance member engagement through data-driven insights. By centralizing quality program data and providing a comprehensive workflow for tracking outreach efforts, CQN enables health plans by:
- Creating a single view of all care gaps
- Tracking provider performance to ensure quality interventions
- Using smart analytics to identify which members are most likely to respond
- Personalizing communications across multiple channels
- Tracking what works and what doesn't to improve continuously
By replacing generic mass mailings with targeted, personalized outreach, health plans can effectively close care gaps, drive meaningful improvements in chronic disease management, and enhance member experiences.
2. Improve Survey Participation and Results
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a critical factor in Star Ratings, reflecting patient satisfaction and experience with their health plans. Low response rates can skew results, making it imperative for health plans to improve survey participation.
Studies show that phone follow-ups can improve CAHPS response rates by 4 to 20 percentage points compared to mail-only outreach. Yet, without an integrated system to manage outreach effectively, many plans fail to maximize their survey responses.
Member Engagement (ME) Navigator enables health plans to:
- Conduct omnichannel outreach via portal, mail, SMS, email, and phone
- Automate survey reminders with AI-powered smart alerts
- Personalize interactions using predictive analytics to engage members most likely to respond
- Track engagement metrics through a dedicated dashboard for continuous improvement
By leveraging the ME Navigator, health plans can optimize patient engagement efforts, which can lead to better survey participation and higher CAHPS scores.
3. Addressing Social Factors to Prevent Hospital Readmissions
Hospital readmissions significantly impact Star Ratings and are a significant cost driver for health plans. Nearly 20% of Medicare patients are readmitted within 30 days, leading to over $17 billion in avoidable costs annually.
A primary contributor to high readmission rates is the influence of social determinants of health (SDOH) factors like housing instability, food insecurity, and lack of transportation. Addressing these barriers requires a data-driven approach to identifying at-risk populations and implementing targeted interventions.
ZeOmega’s SDOH Social Care Platform and Social Care Connect offer a robust solution by:
- Aggregating data from claims, government sources, and community assessments to identify social risk factors
- Connecting members with community-based organizations (CBOs) for essential social care services
- Tracking social care interventions in real time to measure impact and adjust strategies accordingly
- Providing closed-loop referrals to ensure members receive needed support, reducing the likelihood of readmissions
By integrating SDOH analytics with engagement workflows, health plans can proactively address barriers to care, ultimately improving patient outcomes and Star Ratings.
4. Enhancing ECDS Reporting Through Better Member Engagement
As the HEDIS® Electronic Clinical Data Systems (ECDS) reporting standard pushes health plans to capture structured electronic data from diverse sources, the role of member engagement becomes even more critical. High-quality electronic reporting depends not just on clinical systems, but also on proactive, accurate interactions with members. The Jiva Healthcare Enterprise Management Platform supports ECDS reporting efforts by improving the completeness and quality of member data.
By linking engagement strategies directly to clinical quality measures, Jiva enables health plans to improve member participation, enhance data reliability, and ultimately strengthen their HEDIS ECDS submissions.
Bringing It All Together: An Integrated Approach
Health plans that prioritize member engagement are better positioned to improve HEDIS scores, boost Star Ratings, and deliver high-quality care. The combination of technology, data intelligence, and personalized outreach can make a substantial difference in closing care gaps, improving patient experience, and reducing readmissions.
Jiva’s solution suite creates this integrated system through:
- Care Quality Navigator (CQN): Identifies and closes care gaps, tracks provider performance
- Member Engagement Navigator (ME Navigator): Creates personalized communication strategies
- SDOH Social Care Platform: Identifies social risk patterns
- Social Care Connect: Links members with plan-managed community-based organizations
This integrated approach simultaneously improves member experience, clinical outcomes, and quality ratings. As the healthcare landscape continues to evolve, health plans that invest in a meaningful, automated member engagement approach will not only improve their quality metrics but also build trust, loyalty, and healthier populations.
