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.
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