3,262
Additional women tested or treated
(7.1 per 100 eligible)
(7.1 per 100 eligible)
The Accreditation Advantage
NCQA-Accredited Health Plans Perform Better in HEDIS® and CMS Star Ratings
› EXECUTIVE SUMMARY
The Opportunity in Medicare Advantage
Medicare Advantage (MA) now covers more than half of all eligible Medicare beneficiaries. In 2026 that was 35 million people.1 The CMS Star Ratings are a key driver of clinical outcomes, membership growth and financial results for MA plans. Highly rated plans can earn bonus payments from Medicare, and much of that money is required to go back to members in the form of increased benefits, lower cost sharing or reduced premiums.
Quality bonus payments to MA plans are estimated to exceed $13B in 2026, which equates to approximately $400 per member across employer, individual and special needs plans.2
Accredited MA plans outperform non-Accredited plans.
NCQA analyzed the CMS Star Ratings performance of Accredited and non-Accredited MA plans from 2022 to 2024, and the pattern was clear: NCQA Accredited MA plans outperform non-Accredited plans on clinical quality and consistently achieve higher CMS Star Ratings, with a greater share operating at 4 Stars or higher.
The opportunity is significant.
If non-Accredited plans performed at Accredited-plan rates across the 13 HEDIS® measures analyzed, up to 6 more members per 100 eligible would reach their targets for preventive screening and chronic condition management—leading to more than 1.5 million care gap closures. Avoided Medicare medical spend could reach $174M–$320M annually.
› THE FINDINGS
NCQA Accredited Medicare Advantage plans outperform non-Accredited plans
NCQA Accredited Medicare Advantage (MA) plans outperform non-Accredited plans on clinical quality and achieve higher CMS Star Ratings, with a greater share of plans operating at 4 Stars or higher.
These findings are particularly relevant in a market defined by increasing financial pressure, regulatory scrutiny and competition for members. Star Ratings directly influence bonus payments, benefit design and market positioning, making quality performance a strategic priority.
What We Found
- Higher Star Ratings: Higher percentage of Accredited plans operate at 4 Stars or higher.
- Stronger HEDIS® performance: Accredited plans lead on core clinical quality measures across years.
- Better cut point performance: Accredited plans more often clear CMS thresholds (cut points) tied to higher ratings.
- Modestly stronger CAHPS® results: Accredited plans trend higher on several member experience measures.
Why It Matters
If non-Accredited plans performed at Accredited plan rates:
- Care gap closure: 1.5M additional Medicare beneficiaries receiving needed care and services each year.
- Lives saved: 1,712-2,068 breast cancer and colorectal cancer deaths averted.
- Medicare cost savings: $174M to $320M annual medical cost savings, which equates to $1B (Net Present Value) over five years.
- https://www.kff.org/medicare/medicare-advantage-in-2026-enrollment-update-and-key-trends
- https://www.kff.org/medicare/medicare-will-spend-more-than-13-billion-on-the-medicare-advantage-quality-bonus-program-in-2026
- https://www.cms.gov/files/document/effectuated-enrollment-early-snapshot-2025-and-full-year-2024-average.pdf
- https://data.medicaid.gov/dataset/52ed908b-0cb8-5dd2-846d-99d4af12b369?conditions%5b0%5d%5bproperty%5d=year&conditions%5b0%5d%5bvalue%5d=2024&conditions%5b0%5d%5boperator%5d=%3D
- https://www.census.gov/library/publications/2025/demo/p60-288.html
AT-A-GLANCE
66%vs.52%
Accredited plans achieve 4+ Stars 66% of the time,vs. 52% for non-Accredited plans
Medicare Advantage lags other lines of business in plan accreditation.
In the Medicaid, Commercial and Exchange markets, Accreditation is a standard used to set a quality bar—built into contracting, procurement and participation requirements. Plans use it to differentiate, demonstrate operational discipline and win business. In Medicare Advantage—the line of business with high financial stakes through Star Ratings and bonus payments—the rate of Accreditation is the lowest.
This Accreditation gap represents substantial untapped potential for better cost control for plans and meaningful savings for the government entities that fund care.
Source: NCQA Accreditation and HEDIS data and publicly reported enrollment reports.
WHAT CLOSING THE GAP COULD MEAN
1.5M+
Additional care gaps closed for Star Ratings measures*
~$1B
Estimated medical costs avoided over 5 years*
* If non-Accredited plans performed at Accredited plan rates.
Real-world impact calculation inputs are based on findings from research studies related to the HEDIS measures in the CMS Star Ratings. Priced on the specific clinical events each measure averts, at Medicare costs, with shared events counted only once.
› KEY FINDING #1: STAR RATINGS
Accredited plans consistently achieve higher overall Star Ratings year over year.
Accreditation is associated with stronger outcomes and offers a structured framework that plans use to sustain quality improvement over time. NCQA has set quality standards for health plans for more than 35 years and our Health Plan Accreditation is widely recognized as a rigorous framework for quality improvement and operational excellence.
Less variability: Accredited plans also show fewer low-performing outliers and a greater concentration of plans at higher performance levels.
Accredited Plans More Often Score at 4 Stars or Higher
% of MA plans with an overall CMS Star Rating of 4 Stars or higher (Measurement Years 2022–2024)
Source: NCQA Accreditation data and CMS publicly reported Star Ratings performance and Star assignment data.
AT-A-GLANCE
14%
Share of Accredited plans earning 4+ Stars in Measurement Year 2024 vs. non-Accredited plans
› KEY FINDING #2: HEDIS PERFORMANCE
Accredited plans outperform non-Accredited plans across 12 HEDIS measures that are included in the Star Ratings formula.
The advantage observed among Accredited plans suggests that Accreditation is associated with the development of these capabilities in a systematic and repeatable way.
Accredited Plans Outperform Non-Accredited Plans Across 12 of 13 HEDIS Measures
Average performance rates (%), MY 2024
AccreditedNon-Accredited
Osteoporosis Mgt.
+7 PTS
Glycemic Assessment
+6 PTS
Colorectal Screening
+6 PTS
Eye Exam
+5 PTS
Kidney Health
+5 PTS
Breast Cancer Screening
+5 PTS
Transitions of Care
+5 PTS
Blood Pressure Control
+4 PTS
COA – Med Review
+3 PTS
COA – Pain Assessment
+3 PTS
Follow-up After ED
+2 PTS
Statin Therapy
+1 PT
Readmissions
+<1 PT
+4PTS
Average performance advantage of Accredited plans across the 13 HEDIS measures
Source: NCQA Accreditation data and performance rate data from HEDIS, stewarded by NCQA.
AT-A-GLANCE
+4PTS
Average performance advantage of Accredited plans across the 13 HEDIS measures.
› KEY FINDING #3: CUT POINT PERFORMANCE
Accredited plans clear the 4-Star threshold more often—and with less variation.
CMS sets performance thresholds (cut points) that determine whether a plan earns 1 to 5 Stars on each measure. The 4-Star cut point is especially important because plans must earn a rating of 4 Stars or higher to qualify for bonus payments. Even small differences near the 4-Star cut point can swing rating outcomes—and bonus payment eligibility.
Accredited plans have widened their advantage over non-Accredited plans from four more measures exceeding the 4-Star cut point in Measurement Year 2022 to seven more measures in Measurement Year 2024.
Accreditation Promotes Consistency
Accredited plans show fewer low performing outliers and a greater concentration of plans at higher performance levels, as shown in the example below.
PERFORMANCE ACROSS THE CUT POINT
GLYCEMIC STATUS ASSESSMENT (Measurement Year 2024)
ACCREDITED PLANS
NON-ACCREDITED PLANS
Above 4-Star Cut Point
Below 4-Star Cut Point
Cut Point for 4-Star Rating = 87%
6PTS
The performance gap that separates the two groups placing the average Accredited plan above the 4-Star cut point and the average non-Accredited plan below it.
Source: NCQA Accreditation data and CMS publicly reported Star Ratings performance and Star assignment data.
AT-A-GLANCE
9
Accredited
vs.
2
Non-Accredited
Number of HEDIS measures where the Accredited plan average exceeded the 4-Star cut point versus the non-Accredited plan average in Measurement Year 2024.
› KEY FINDING #4: REAL-WORLD IMPACT
What it could mean if non-Accredited plans performed as well as Accredited plans.
Differences in performance translate to real-world impact in terms of care gaps closed, Medicare costs averted and lives saved.
Modeled Population Health Impact (Measurement Year 2024 Data)
| HEDIS Measure | Additional Members Reaching Target | Clinical Outcome / Lives Saved |
|---|---|---|
| Breast Cancer Screening | 128K(5.1 per 100 eligible) | 51–154Cancers detected in earlier stages |
| Colorectal Cancer Screening | 328K(5.7 per 100 eligible) | 295–656Cancers prevented and 134–524 cases caught earlier |
| Controlling High Blood Pressure | 186K(3.4 per 100 eligible) | 780–1,801Heart failure events and strokes prevented |
| Eye Exam for Patients With Diabetes | 149K(5.9 per 100 eligible) | 149–804Vision loss cases prevented |
| Glycemic Status Assessment for Patients With Diabetes | 144K(5.7 per 100 eligible) | 808–2,295Diabetes-related deaths prevented |
| Kidney Health Evaluation for Patients With Diabetes | 197K(5.9 per 100 eligible) | 197–983Years of dialysis prevented |
| Follow-Up After Emergency Department Visit | 33K(1.7 per 100 eligible) | 82–655Emergency department revisits and admissions prevented |
| Osteoporosis Management In Women Who Had a Fracture | 3,262(7.1 per 100 eligible) | 34–65Fractures prevented in older women |
| Plan All-Cause Readmissions | 5,254(0.3 per 100 eligible) | 5,254Avoidable readmissions prevented |
| Statin Therapy | 7,987(1.2 per 100 eligible) | 80–112Recurrent cardiovascular events prevented |
| Transitions of Care | 156K(5.8 per 100 eligible) | 1,641–4,690Readmissions prevented |
Source: Real-world impact calculation inputs are based on findings from research studies related to the HEDIS measures in the CMS Star Ratings. All studies are referenced on our methods page at: https://www.ncqa.org/accreditation-advantage-methods.
MEDICARE COSTS AVERTED (IN 2026 DOLLARS)
IF ACCREDITED-LEVEL PERFORMANCE IS SUSTAINED BY NON-ACCREDITED PLANS
$174M–$320M
Annual Medicare cost savings
$795M–$1.5B
5-year Medicare cost savings (Net Present Value)
$1.5B–$2.7B
10-year Medicare cost savings (Net Present Value)
Priced on the specific clinical events each measure averts, at Medicare costs, with shared events counted only once.
› KEY FINDING #5: CAHPS PERFORMANCE
Accredited plans perform better on CAHPS measures of patient experience.
Similar to the HEDIS measures, most CAHPS measures show that Accredited plans trend toward better performance, but with greater variability and smaller differences. Even small variations can be significant for plans that sit close to a cut point in the Star Ratings.
6 of 7 measures favor Accredited plans
Accredited Plans Perform Better Than Non-Accredited Plans on Most CAHPS MeasuresPerformance gap in percentage points, MY 2024
| CAHPS Measure | Accredited Avg | Non-Accredited Avg | Performance Gap (percentage points) |
|---|---|---|---|
| Flu Vaccine | 69.23% | 65.75% | +3.48 |
| Health Plan Rating | 87.54% | 86.72% | +0.82 |
| Health Care Quality | 87.18% | 86.63% | +0.55 |
| Customer Service | 90.53% | 90.23% | +0.30 |
| Getting Care | 81.49% | 81.25% | +0.24 |
| Getting Appointments | 83.88% | 83.83% | +0.05 |
| Care Coordination | 87.24% | 87.28% | -0.04 |
Notes: 1. Gap = Accredited plan average minus non-Accredited plan average (percentage points). Positive values indicate Accredited plans score higher. 2. Analysis includes 661 unique plans in MY 2024.
CAHPS measures add aMEMBER EXPERIENCE LENSto plan performance
Accredited plans generallyTREND HIGHERon measures of access, quality and communication
Source: NCQA Accreditation data and CMS publicly reported Star Ratings performance and Star assignment data.
The real-world impact of Accreditation.
Performance differences between Accredited plans and non-Accredited plans have real-world impact in terms of gap closure, disease progression slowed, lives saved and Medicare costs averted. Select a measure to learn why it matters and what it could mean if non-Accredited plans performed at the same level as Accredited plans.
Source: NCQA Accreditation data and CMS publicly reported Star Ratings performance and Star assignment data.
› HEDIS MEASURE SPOTLIGHT
Osteoporosis Management in Women Who Had a Fracture
Why this measure matters
- Osteoporosis-related fractures can have serious consequences for health and independence.
- Women who experience a fragility fracture are more likely to experience another fracture.
- Bone density testing and prescription medications can help prevent future fractures.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
34–65
Fractures prevented in older women
$1M–$3M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Glycemic Status Assessment for Patients with Diabetes
Why this measure matters
- Poorly managed diabetes raises the risk of serious complications, including kidney disease, vision loss and cardiovascular events.
- Regular glycemic status assessment is essential to guide treatment and keep glucose levels in a safe range.
- The Glycemic Status Assessment for Patients With Diabetes (GSD) measure tracks whether members' glucose control was assessed and within range.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
144K
Additional people with controlled blood sugar
(5.7 per 100 eligible)
(5.7 per 100 eligible)
808–2,295
Diabetes-related deaths prevented
$21M–$46M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Eye Exam for Patients With Diabetes
Why this measure matters
- Left unmanaged, diabetes can lead to vision loss and blindness.
- Regular eye exams are the best way to reduce the risk of blindness and maintain a healthy and productive life.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
149K
Additional people screened
(5.9 per 100 eligible)
(5.9 per 100 eligible)
149–804
Vision loss cases prevented
$3M–$18M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Kidney Health Evaluation for Patients With Diabetes
Why this measure matters
- Diabetes is the leading cause of kidney disease.
- Undiagnosed chronic kidney disease can increase the chances of heart disease, stroke, kidney failure and end-stage renal disease.
- Kidney health testing can help people with diabetes understand and take action to lower their risk.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
197K
Additional people screened
(5.9 per 100 eligible)
(5.9 per 100 eligible)
197–983
Years of dialysis prevented
$9M–$47M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Colorectal Cancer Screening
Why this measure matters
- Colorectal cancer is the second leading cause of cancer-related death in the United States.
- Screening can identify precancerous polyps before cancer develops.
- Early detection drives much better survival outcomes.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
328K
Additional people screened
(5.7 per 100 eligible)
(5.7 per 100 eligible)
295–656
Cancers prevented, plus 134–524 cases caught earlier
$39M–$140M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Breast Cancer Screening
Why this measure matters
- Breast cancer is the second most common type of cancer among women in the U.S.
- Mammograms are the best method to detect breast cancer early—when it is easier to treat.
- Early detection can provide people with a greater range of treatment options, such as less aggressive surgery and less toxic chemotherapy.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
128K
Additional people screened
(5.1 per 100 eligible)
(5.1 per 100 eligible)
51–154
Cancers detected in earlier stages
$4M–$13M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Transitions of Care
Why this measure matters
- The Medicare population includes older adults and individuals with complex health needs who often experience fragmented care.
- High quality care transitions can lower the risk of readmissions, adverse events and drug-related errors, and improve patient satisfaction.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
156K
Additional people with coordinated care transitions
(5.8 per 100 eligible)
(5.8 per 100 eligible)
1,641–4,690
Readmissions prevented
Costs averted are included in the Plan All-Cause Readmissions measure.
› HEDIS MEASURE SPOTLIGHT
Controlling High Blood Pressure
Why this measure matters
- High blood pressure is a leading contributor to heart disease and stroke, among the top causes of death in the United States.
- Consistent blood pressure control substantially lowers the risk of heart attack, stroke and kidney damage.
- The Controlling High Blood Pressure (CBP) measure tracks the share of members whose blood pressure was adequately controlled.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
186K
Additional people with controlled blood pressure
(3.4 per 100 eligible)
(3.4 per 100 eligible)
780–1,801
Heart failure events and strokes prevented
$17M–$48M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Follow-Up After Emergency Department Visit for People With High-Risk Multiple Chronic Conditions
Why this measure matters
- Individuals with multiple high-risk chronic conditions are more likely to experience fragmented care and adverse healthcare outcomes.
- They often face communication lapses between the emergency department and outpatient care teams.
- Timely follow up after an emergency department visit can reduce the risk of medication errors, hospitalization and other adverse events.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
33K
Additional people with timely follow-up after an ED visit
(1.7 per 100 eligible)
(1.7 per 100 eligible)
82–655
Emergency department revisits and admissions prevented
Costs averted are included in the Plan All-Cause Readmissions measure.
› HEDIS MEASURE SPOTLIGHT
Statin Therapy for Patients With Cardiovascular Disease
Why this measure matters
- Cardiovascular disease is the leading cause of death in the U.S.
- Statin therapy can lower blood cholesterol and reduce the risk of major cardiovascular events.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
7,987
Additional people receiving statin therapy
(1.2 per 100 eligible)
(1.2 per 100 eligible)
80–112
Recurrent cardiovascular events prevented
Costs averted are included in the Controlling High Blood Pressure measure.
› HEDIS MEASURE SPOTLIGHT
Plan All-Cause Readmissions
Why this measure matters
- Readmission to the hospital within 30 days of discharge is frequently avoidable and can lead to adverse outcomes for patients.
- Initiatives to improve communication with patients and their caregivers, coordinate care after discharge and improve the quality of care during the initial admission can avert many readmissions.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
5,254
Additional patients receiving appropriate care after discharge
(0.3 per 100 eligible)
(0.3 per 100 eligible)
5,254
Readmissions prevented
$102M–$112M
Annual Medicare costs averted
› HEALTH PLAN PERSPECTIVES
How Accredited plans operationalize standards to drive performance.
Strong HEDIS and Star Ratings performance is rarely the result of a single program or intervention. It requires a long-term investment in data, infrastructure and clinical programs to improve the health of members and communities. NCQA interviewed quality and clinical leaders from high-performing Accredited MA plans and several common themes emerged:
Create a Culture of Quality
The most successful MA plans view quality as an organizational responsibility, not the work of a single department. Leaders prioritize quality from the top down and create shared accountability for outcomes.
Use Accreditation as a Roadmap for Improvement
Many plans describe Accreditation as a strategic improvement framework—a structured way to identify gaps, strengthen accountability and drive organizational performance.
Double Down on Data Acquisition and Analysis
High-performing MA plans view data as a strategic asset. They are combining multiple streams of information—claims, clinical, provider, pharmacy and member experience data—to create actionable intelligence that supports quality improvement and population health management.
Focus on Whole-Person Care
Successful MA plans go beyond traditional claims-based analysis to develop a comprehensive understanding of each member’s health status, risks and needs. The focus shifts from simply identifying care gaps to understanding the barriers that created those gaps and deploying targeted interventions that make it easier for members to receive the care they need.
Build Strong Care Delivery Partnerships
The strongest plans do not simply encourage clinicians to improve quality performance. They actively equip them to succeed—from providing actionable data to support value-based contracting to investing in equipment and infrastructure to improve access to care.
Invest in Communities and Address Needs Beyond Clinical Care
Many drivers of population health occur outside the walls of traditional healthcare. As a result, high-performing MA plans are investing in community partnerships and programs that address access, health literacy, social needs and member engagement.
Accredited MA Plan Success Stories
Find out how high-performing Accredited MA plans are investing in population health strategies that improve HEDIS and Stars Performance—and how Accreditation serves as a roadmap for success.
SERVICE AREA
Florida
MEDICARE MEMBERS
24,000
IN MEDICARE MARKET SINCE
2006
SERVICE AREA
New York
MEDICARE MEMBERS
74,000
IN MEDICARE MARKET SINCE
1999
SERVICE AREA
[Add service area]
MEDICARE MEMBERS
[Add members]
IN MEDICARE MARKET SINCE
[Add year]
SERVICE AREA
Pennsylvania
MEDICARE MEMBERS
85,000
IN MEDICARE MARKET SINCE
2006
SERVICE AREA
[Add service area]
MEDICARE MEMBERS
[Add members]
IN MEDICARE MARKET SINCE
[Add year]
SERVICE AREA
Michigan
MEDICARE MEMBERS
270K
IN MEDICARE MARKET SINCE
2005
MY 2024 STAR RATING FOR COLORECTAL CANCER SCREENING:
5 Stars
SERVICE AREA
Pennsylvania
MEDICARE MEMBERS
226,000
IN MEDICARE MARKET SINCE
2001
Improving Community Health Through Accreditation: Capital Health Plan’s High-Touch Approach to Quality
NCQA Accreditation is closely aligned with Capital Health Plan’s (CHP) mission to improve the health of the communities it serves. As a longstanding fixture in the community since 1982, CHP operates in nine counties in the Florida panhandle, eight of which are rural, making access to healthcare a significant challenge. Rather than viewing Accreditation as a compliance exercise, the plan uses NCQA’s quality framework to develop programs that bring care closer to members and reduce barriers to accessing needed services.
Because of its relatively small size and deep roots in the community, CHP is able to build personal relationships with members and providers in ways that larger organizations often cannot. Roughly one-third of members receive care from CHP-employed clinicians, while two-thirds are served by affiliated practices. This hybrid model allows CHP to align quality strategies across both employed and affiliated practices, creating consistency in how care gaps are identified and closed.
“Our quality improvement program for NCQA Health Plan Accreditation feeds directly into our population health strategies. Through those programs, we gather documentation to show how we are improving the health of the community, which is one of our key pillars. It all ties together.”
Mary Goble, Former Director, Clinical Quality and Performance Improvement Department, Capital Health Plan
Making Strategic Investments to Improve Access to Care
NCQA Accreditation standards help guide the programs and partnerships that define CHP’s population health approach. The plan has made strategic investments that improve access to care in the rural communities it serves by bringing resources directly to practices and community settings.
- Centralizing ancillary services. CHP has invested in equipment and staff to expand access to ancillary services like x-rays and mammography within its owned medical practice and offers affiliated clinics the option to schedule procedures in its facilities.
- Increasing access to eye exams. CHP developed an eye clinic within its medical practice and provides care gap lists for the staff to contact members with diabetes who are overdue for their eye exams.
- Offering non-sedated colonoscopies. CHP hired an Advanced Practice Registered Nurse who is trained to perform colonoscopies without IV sedation so members can drive themselves home or return to work afterwards. This approach removes one of the common barriers for members to complete this service.
- Hosting health fairs. CHP invites members to attend health fairs where CHP employed physicians and nurses perform blood draws and blood pressure checks and enter the information into the EHR.
Results
Capital Health Plan exceeded the CMS 4-Star cut point for nine HEDIS measures included in the CMS Star Ratings in MY 2024.
“As a primary care provider, I rely on HEDIS measures to help me deliver consistent, evidence-based care for patients living with chronic conditions. For these patients, preventive care is not separate from treatment; it is an essential part of managing conditions like diabetes, hypertension, and COPD. By focusing on prevention through HEDIS, I can help patients stay more stable, avoid unnecessary hospitalizations and improve their long-term health and quality of life.”
Dr. Cielo Rose, Physician Manager at the Nancy Van Vessem Center for Healthy Aging, Capital Health Plan
CDPHP®: Accreditation Lays the Foundation for Excellence
For Capital District Physicians’ Health Plan, Inc. (CDPHP), quality improvement is not a department. It is an organization-wide commitment that impacts every member interaction, provider partnership and strategic decision. A regional health plan serving just under 74,000 Medicare Advantage members in upstate New York, CDPHP has built a comprehensive approach to population health that combines data-driven interventions, close provider collaboration and a deeply embedded culture of quality.
At the center of that strategy is NCQA Health Plan Accreditation. Rather than treating Accreditation as a compliance exercise, CDPHP uses NCQA standards as the foundation for continuous improvement and a roadmap for delivering better care and outcomes.
“When you are an NCQA Accredited entity, you are demonstrating a high standard of commitment to your members. It shows that you are willing to go through scrutiny and validation by NCQA to become the best health plan you can be. NCQA Accreditation is the roadmap or guidebook to get you there.”
Cynthia Farrelly, Manager, Quality Program Governance, CDPHP®
Making Strategic Investments to Improve Outcomes
CDPHP’s quality improvement strategy begins with understanding its population and identifying areas where members need the most support. Its investments in population health range from technology and analytics to member outreach and provider engagement.
- Building provider partnerships. A cornerstone of the plan’s approach is its partnership with providers. Through value-based incentives and ongoing collaboration, CDPHP works closely with physician practices to identify care gaps, prioritize interventions and engage members in preventive and chronic care services.
- Investing in information sharing. The health plan continuously shares performance reports and care gap information with providers, helping practices identify members who need appointments, screenings or follow-up care. At the same time, provider feedback helps CDPHP understand barriers to care and develop practical solutions.
- Targeted member communications. The plan has developed sophisticated communication strategies that target the right members with the right message at the right time. These communications go beyond reminders. Members can request assistance with scheduling appointments, respond to outreach and connect with quality staff who help overcome barriers to care.
- Providing a seamless member experience. The CDPHP quality improvement strategy enables internal collaboration by creating a single source for everything that is going on with a member, whether it is a survey, outreach mailing, customer service call or care management interaction. It allows employees to have the full picture and provides a more consistent experience for members.
- Viewing data through an equity lens. CDPHP measures performance through multiple lenses, including analysis of health equity data. The organization routinely examines HEDIS measures by race, ethnicity, language, geography and other factors to identify disparities and inform interventions.
Results
CDPHP exceeded the CMS 4-Star cut point for six HEDIS measures included in the CMS Star Ratings in MY 2024.
“People come up to me and ask, ‘How do you do it?’ It’s like they’re looking for the secret sauce. I tell them that the secret sauce is that everyone has to be invested. Everyone has to own it. Everyone has to come to work every day knowing this is what we need to do.”
Michael Farina, Vice President, Healthcare Quality, CDPHP®
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Meeting Members Where They Are: Geisinger’s Whole-Person Approach to Population Health and Quality Improvement
For Geisinger Health Plan (GHP), improving quality starts with a simple but powerful philosophy: care for the whole person, not just a diagnosis. That means addressing clinical needs alongside behavioral health, social determinants of health and barriers to care. GHP is part of Geisinger, an integrated healthcare delivery organization that serves communities across Pennsylvania. Its goal is to be the best by providing exceptional care to all and leading healthcare forward.
NCQA Accreditation can serve as an engine for quality improvement. By providing a structured framework for population health management, performance measurement and organizational accountability, Accreditation helps transform quality initiatives into measurable gains in HEDIS performance, Medicare Star Ratings and member outcomes.
“We’ve been on a bit of a journey with population health and the one thing we really focus on is whole-person care. It is important to meet our members where they are, and where they want us to meet them.”
Erin Griffith, Director, Quality Management, Geisinger Health Plan
Making Strategic Investments in Population Health
GHP’s population health approach extends well beyond traditional case management. It requires an understanding of the needs of the entire population. The plan has invested in programs that bring care directly to members, address social needs and provide highly specialized care for members with complex needs.
- Delivering home-based services. As part of its philosophy of meeting members where they are, GHP offers home-based programs like case management and nurse practitioner services—not just for members who are homebound, but for members who prefer to receive care that way. The plan also promotes virtual behavioral health services to provide more timely access and align with member preferences.
- Addressing social needs for all members. Historically, social needs assessments were primarily focused on members in case management, but GHP recently launched a social needs hub for its entire membership. The program connects members with specialized support for challenges such as food insecurity, transportation issues, housing instability and social isolation. Certified community health workers and behavioral health specialists work together to connect members with resources and close care gaps before they become larger health concerns.
- Investing in the right vendor partners. GHP recognizes that it can’t be everything to everyone. That’s why it invests in strategic partnerships with organizations that specialize in managing complex conditions such as kidney disease and cancer. These partnerships supplement GHP’s internal expertise while helping members access specialized support, education and care coordination. At the same time, GHP learns from these partners and integrates successful approaches into its operations.
- Looking beyond the data. Data serves as the foundation for GHP’s population health strategy. The plan relies on robust data sources to identify member needs, uncover gaps in care and prioritize interventions. But data alone is not enough. GHP’s population health strategies also account for individual circumstances and social factors that may not always appear in claims or clinical data.
Results
GHP exceeded the CMS 4-Star cut point for seven HEDIS measures included in the CMS Star Ratings in MY 2024 for its HMO plan and eight measures for its PPO plan.
“Our Star Ratings reflect thousands of daily actions focused on keeping people healthy and engaging them in their care. It’s about the care we wrap around our members, how we use data to drive our decisions and how we try to personalize care as much as we can.”
Eileen Evert, Senior Director, Quality and Accreditation, Geisinger Health Plan
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Closing Every Gap, One Member at a Time
Priority Health developed a “Next Best Action” process to guide member outreach. The approach identifies the next action required to close a care gap for each member. Outreach generally follows a stepped escalation model:
- Initial letter or email prompting a primary care visit and outlining needed services.
- More frequent outreach after six months if care has not been completed.
- A phone call from the care team to help schedule an appointment or address other barriers to care.
- Home screening kits mailed to members who still do not complete needed screening.
The program relies on a continuous flow of claims and chart review data to target members most in need of support. Priority Health’s leadership attributes improved colorectal screening performance to this structured, data-enabled, multi-channel approach.
UPMC Health Plan: Accreditation Supports Whole-Person Care
For UPMC Health Plan, NCQA Accreditation supports a whole-person approach to care and better outcomes. As part of the University of Pittsburgh Medical Center (UPMC) integrated health care delivery system, UPMC Health Plan is committed to providing its members with better health, more financial security and the peace of mind they deserve.
Today, the health plan serves approximately 226,000 Medicare Advantage members across multiple plan offerings while maintaining a strong focus on population health and quality improvement.
“From my perspective, the value is that Accreditation really encourages us to move beyond good intentions and helps us demonstrate that we have a reliable structure for understanding our population, identifying gaps, acting on those gaps and working to sustain improvement over time.”
Lisa Gerdes, Director, Quality Improvement, UPMC Health Plan
Making Strategic Investments to Improve Outcomes
At UPMC Health Plan, population health is not viewed as a collection of individual programs. Instead, it is an integrated strategy that brings together clinical teams, care management, quality improvement, analytics, providers, pharmacy and community engagement staff to address the needs of members holistically.
NCQA Accreditation provides a framework that helps align these efforts and turn quality goals into sustainable practices, such as:
- Creating a more complete picture of member health. One of UPMC Health Plan’s biggest investments has been data acquisition and integration from a variety of sources—clinical, supplemental, health risk assessments and member experience surveys—to gain a more complete understanding of the members it serves.
- Identifying and removing barriers to care. The UPMC Health Plan teams are relentlessly curious, using data to understand the barriers to care and, more importantly, why those barriers exist. Armed with that information, they develop creative ways to intervene earlier and more effectively to remove those barriers.
- Creating targeted pathways to care. The team groups members into different populations based on their risk level and develops individualized outreach, communication plans and care paths to engage members in their care through health coaching, care management, medication adherence reviews and visits with their primary care clinician or specialist.
- Integrating community engagement approaches. Historically, UPMC Health Plan’s quality initiatives were focused on what happened in traditional care settings, but it has broadened that approach through community partnerships and outreach efforts designed to meet members where they live, work and play. These holistic approaches focus on access to care, health literacy, social and emotional needs and improving members’ ability to understand their benefits.
“Once you hit a certain performance level, I think you have addressed all your low-hanging fruit opportunities. NCQA has got us thinking about different populations and the people we’re missing. We have seen big improvements in our Star Ratings and quality performance because of how we have been able to come together and focus not just on the individual measures, but on our overall population health strategy and engaging with those high-risk populations.”
Mariah Osborn, Director, Medicare Stars, UPMC Health Plan
“During last year’s annual enrollment our plan nearly doubled in size, and that’s been a huge eye-opener for us because we are bringing on new members with limited information about their health history. That’s where our laser-focused quality programs are helping us to quickly assess the population and get the care they need.”
Vice President, Quality and Clinical Integration
at a Medicare Advantage Plan
› IMPLICATIONS
How these findings relate to the broader healthcare industry and what to do next.
These findings point to specific actions for plans and policymakers who want to close performance gaps, reduce financial risk and improve outcomes.
FOR MEDICARE ADVANTAGE PLANS
Accreditation and Star Ratings work together
Plans that pursue Accreditation are building the exact infrastructure that drives Star Ratings results. These investments compound and do not compete.
Focus on clinical quality as the primary driver of Star Ratings performance
Strong execution on HEDIS measures is a consistent and controllable lever for improving overall performance.
Prioritize performance at critical thresholds
Small improvements near CMS thresholds (cut points) can meaningfully influence Star Ratings outcomes, making targeted interventions particularly impactful.
Invest in repeatable quality improvement capabilities
Plans that embed structured processes for identifying care gaps, engaging providers and tracking performance are better positioned to sustain results over time.
FOR POLICYMAKERS & CMS STAKEHOLDERS
Accreditation aligns with value-based care priorities
Accreditation reinforces performance on measures directly tied to outcomes, supporting broader efforts to improve quality and accountability.
Performance gaps have real public health consequences
The difference between Accredited and non-Accredited plans translates into hundreds of thousands of missed screenings and thousands of preventable deaths per year.
Standardization of quality improvement practices promotes consistency
Accreditation provides a consistent framework, helping reduce variability in how plans approach quality improvement.
Independent validation strengthens plan oversight
Accreditation provides an evidence-based signal of a plan's ability to execute on quality measures over time.
