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The final rule dropped! No big surprises, but the impact isn’t evenly distributed.

The final rule dropped! No big surprises, but the impact isn't evenly distributed. GettyImages 1494221064

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By Jessica Assefa, Partner, Health Plan Consulting, Press Ganey.

CMS just dropped the final rule we’ve all been waiting for.

No real surprises, folks. They finalized pretty much everything from the proposed rule. The only change? Diabetes eye stays. Everything else is moving forward.

At a high level, we’re seeing the same direction CMS has been signaling for a while: fewer operational measures, more emphasis on outcomes and member experience, and continued alignment across programs.

The more interesting story, however, isn’t what methodologies and measures are leaving—more so whom this impacts, and how.

The visuals make that pretty clear. A little over half of the contracts won’t make a significant enough move to gain/lose a half Star, but when they do, the downside isn’t evenly distributed. Contracts specific to special needs plans (SNP)-only contracts show more downside pressure and very limited upside in terms of rebate percentage increase and Quality Bonus Payment (QBP) gain. Partial and non-SNP contracts have more room to move. Larger contracts look more stable.

That’s not random. CMS continues to move toward outcomes, and those outcomes don’t look the same across all member populations—especially when you start looking at duals. This is where plans need to shift how they examine their own data. It’s not just “what measure do I need to move?” anymore. It’s who, inside each measure denominator, is driving that performance. Jay Palmer, an industry expert and recent guest of ours on Press Ganey’s Rising Stars podcast calls this “denominator intelligence.” If you haven’t already, it’s time to start doing meaningful segmentation:

  • Dual vs. non-dual
  • High-risk vs. stable populations
  • Metro vs. rural

And if you have good race, ethnicity, and other demographic data points, keep the segmentation going!

You already have most of this data. It’s in your HEDIS reporting. It’s been sitting on display measures. It’s in your internal analytics and your historic, identified, full-cohort HOS data. (If you don’t know where to find that, shoot me an email jessica.assefa@pressganey.com, I’ll send you the pathway.) The question is whether you’re using it to actually understand where performance is breaking down.

How do your dual populations perform on outcomes compared to non-duals? Where are you seeing gaps in follow-up, engagement, or care coordination? Where are members falling out of the system entirely? Because those are the places where these changes are going to hit. And once you see it, the next question becomes: What are you actually going to do differently for those members?

This is where it moves beyond Stars mechanics and into real operational decisions:

  • Do you need to rethink your benefit design to better support specific subsets of members?
  • Are you putting the right services in the hands of the members who actually need them?
  • Are your interventions designed for the population, or just applied broadly and hoping they stick?

The same applies to behavioral health. If you’re a dual-heavy plan, you already know behavioral health is a barrier for a meaningful portion of your population. That shows up in outcomes, in adherence, in engagement…in everything. So, the question isn’t just: “Do we have a depression screening process?” CMS is driving us to outcomes, the questions now become:

  • Can we identify members who are likely struggling right now?
  • Do we have a way to connect them to care that actually works for them?
  • Are we removing barriers like transportation, access, and provider availability?

For some members, that may mean integrating behavioral health directly into clinical, quality, and care management workflows. For others, it may mean expanding access to telehealth or virtual options that better meet them where they are. And, just as importantly, can you actually see what’s happening? Do you have clear data flow and communication between your plan, providers, vendors, and behavioral health network? Can you track whether follow-up is happening, or are you relying on assumptions?

With the new measure coming in, and with HOS already weighted the way it is, that visibility matters. At the end of the day, this rule doesn’t require a brand-new playbook. But it does require plans to be more intentional about whom they’re focusing on and how they’re supporting them. The plans that do well here aren’t going to be the ones chasing every measure equally. They’re going to be the ones that understand where their risk actually sits within their population, and build strategies around that.

This is hard work. There isn’t a tip or trick that’s going to get us there (CMS just removed all those easy buttons). It takes time, resources, and real investment. And, as quality leaders, we need to be able to tell that story clearly, so the people making budget decisions understand what’s at stake. Because the Stars ROI is real. And so are the people behind it.

As my friend and Stars leader Brendan Generelli says: “At the end of the day, do the right thing, and the Stars will follow.”