黑料不打烊 Insights | 黑料不打烊 Weekly Roundup

Filter by topic:

Receive timely expert insights on topics you care about.

82 Results found.

CMS Quality Conference 2026: CMS Signals a Faster Path from Policy to Practice in Quality

The Centers for Medicare & Medicaid Services (CMS) convened the at a moment when healthcare quality policy is increasingly being shaped through formal rulemaking as well as informal policy signals and implementation vehicles. The discussions reflected CMS鈥檚 core priorities鈥攚ellness and prevention, digital infrastructure, patient safety, and program integrity鈥攁nd reinforced a broader theme that CMS intends to continue to move faster to advance these priorities than traditional regulatory timelines allow.

黑料不打烊 (黑料不打烊) experts attended QualCon and are working with healthcare organizations as they interpret these signals and prepare to implement the policy priorities highlighted during the conference. This article describes these cross-cutting issues and highlights strategies and actions healthcare entities can take now.

Moving Faster Requires Different Approaches to Policy and Implementation

CMS Administrator Dr. Mehmet Oz emphasized CMS鈥檚 increasing use of voluntary commitments, public-private collaboration, Requests for Information (RFIs), and other informal policy tools as alternatives or precursors to formal requirements, creating an imperative for early stakeholder engagement.

CMS leaders highlighted stakeholder convenings as a key vehicle to drive change outside of regulatory processes, including the pledge by health plans to streamline and improve听听requirements.听These commitments听may听signal听future regulatory听mandates听and shifts in the marketplace.听
罢丑别听听provides听the foundation for quality initiatives.听罢丑别听CMS听Administrator听highlighted听the 600-plus organizations that have committed to the goals of听the听CMS Health Tech Ecosystem,听including companies听that听support conversational听artificial intelligence (AI)听assistants听that听would make听ingestion听and sharing of data with healthcare providers easier through the 鈥淜ill the Clipboard鈥� efforts, and听have pledged听to support interoperability.听
CMS听is using听listening sessions听and听RFIs听to听shape听the direction听and drive quality听policy.听The agency听leaders invited听new ideas听and reinforced the value of feedback received听through听RFIs, citing examples such as the听, Medicare Advantage improvements, and the RFI听on听. CMS leaders also convened sessions pertaining to patient safety, dialysis care, and best practices for medication for treatment of opioid use disorder, signaling these are areas under consideration for policy development.听

Health and Wellness Positioned as a Core Component of Quality Efforts

QualCon prominently featured CMS鈥檚 commitment to promoting health and wellness. Dr. Oz discussed underutilization of existing benefits, such as annual wellness visits, and CMS Deputy Administrator and Director of the Center for Medicare, Chris Klomp, focused on community-based approaches to prevention. Mr. Klomp also spoke of ongoing interest in moving physician payment toward primary care and away from specialty procedures.

CMS officials highlighted new Center for Medicare and Medicaid Innovation (Innovation Center) models, such as and , which are aligned with the Administrator鈥檚 policy priority of empowering patients. CMS officials also acknowledged challenges to behavioral change and the levers CMS is employing in new models, including technology and incentives for beneficiaries, partnerships, and community health workers.

Digital Infrastructure Framed as Necessary for Quality Reforms

QualCon also emphasized making quality measurement fully digital, specifically using FHIR庐 (Fast Healthcare Interoperability Resources) specifications. Agency officials reported having FHIR specifications for 70+ measures and characterized FHIR as the standard for new measures. Use of FHIR aligns with broader interoperability rules, including requiring state Medicaid programs and payers participating in public programs to use FHIR for electronic prior authorization by January 2027.

Quality measurement leaders spoke about the value of integrating quality data in real time and the move from 鈥渓agged scorecards鈥� to 鈥渃ontinuous intelligence.鈥� Notably, attendees expressed enthusiasm about the potential for AI to support measurement and personalization of quality, measures addressing trajectories of care over time, and new approaches to risk adjustment.

Application of AI to Patient Safety Is on the Horizon

Patient safety discussions focused on the potential for AI鈥慹nabled tools to identify risk earlier and prevent harm, particularly with regard to medication safety and error prevention. CMS speakers emphasized that realizing these gains depends on intentional governance, standardized workflows, and patient involvement in AI development and deployment. Rather than positioning AI as a substitute for clinical judgment, sessions framed it as an augmentation tool requiring clear safeguards and accountability.

Avoiding Fraud, Waste, and Abuse

CMS leaders noted the potential to avoid fraud, waste, and abuse through a cross-functional fraud detection center that can analyze claims in real time. CMS also discussed collaboration with states and private insurers and encouraged external input.

Medicaid Discussions

Medicaid received more limited attention at this conference. CMS Medicaid officials reiterated interest in having fewer quality measures and engaged in discussion with state leaders on how to focus quality efforts. They highlighted learnings about the Medicaid early, periodic, screening, diagnosis, and treatment (EPSDT) program and from CMS Innovation Center models centered on maternal health and substance use disorder care.

What We鈥檙e Watching Next

Following QualCon 黑料不打烊 experts are continuing to follow several federal quality-related initiatives that affect plans, health systems, states, and other healthcare delivery organizations include:

How CMS translates voluntary commitments and听Health Tech Ecosystem initiatives into听lasting听policy expectations听for transforming quality听
The pace at which digital quality measurement shifts from pilot to standard practice听
How AI governance frameworks evolve alongside听additional听real-world听use cases in quality and safety听

Connect with Us

黑料不打烊, including Leavitt Partners and Wakely, work with healthcare organizations to navigate the transition to digital quality measurement and act upon digital quality data to improve healthcare delivery.

Wakely uses analytics-driven operating design and return on investment (ROI) analysis, clinical data acquisition models and tools, and pilot-based validation of measure rates and processing performance to support scalable digital quality measurement (dQM) adoption, as outlined in the .

Leavitt Partners is working with federal agencies on a number of activities related to the CMS Health Tech Ecosystem and interoperability, including the Kill the Clipboard initiative, which was informed by a seminal . In addition, Leavitt Partners convenes the , which is working to solve both technical and policy issues in digital quality measurement.

For听details, contact听our experts below.

Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care

Read Blog

The Centers for Medicare & Medicaid Services (CMS) has officially opened the window for the (RHTP)鈥攁 $50 billion federal initiative designed to stabilize and transform rural health systems across the country. This one-time opportunity allows states to submit a comprehensive plan that could redefine how rural communities access care, manage chronic conditions, and sustain their healthcare infrastructure.

As outlined in our earlier In Focus article, , RHTP represents one of the most significant federal investments in rural health in decades.

Applications must be signed by governors and submitted by November 5, 2025, and awards are expected by December 31, 2025, providing states with a very narrow window to act.

The remainder of this article explains key aspects of the RHTP application, including the evaluation and scoring aspects. Notably, the structure of the scoring system will reward states that are already aligned with these , as well as those willing to implement new initiatives or make state policy changes to achieve alignment.

Program Overview and Funding Structure

Created under HR.1, the 2025 Budget Reconciliation Act, the RHTP allocates $10 billion annually from federal fiscal year (FY) 2026 to FY 2030, totaling $50 billion over five years. Funding is split into two tranches:

Tranche 1 (Baseline funding): $25 billion distributed evenly听across all states with approved applications.
Tranche 2 (Workload funding): $25 billion distributed based on CMS scoring criteria, which include:
- The percentage of the state population in rural census tracts
- The proportion of rural health facilities in the state
- The financial and operational status of hospitals
- Other factors explained in the RHTP application notice

States must submit a single, one-time that covers the full five-year period. Stand-alone provider applications will be declined. Hence, states must coordinate across agencies, providers, and stakeholders to develop a unified transformation strategy.

Importantly, this award is not a grant; rather, it is a cooperative funding agreement, which means CMS will play an active role in oversight and collaboration. States must be prepared to meet higher standards of accountability, transparency, and performance monitoring. According to the RHTP application, continued funding requires states to demonstrate satisfactory progress toward implementing their plan.

Application Requirements and Strategic Priorities

To be eligible for funding, states must submit a Rural Transformation Plan that addresses eight core priorities as follows:

Within these core priorities, state plans must propose activities that address several specific issues.

Technical Factor Weighting for Workload Funding Reflects Federal Policy Priorities

CMS outlines the eligibility criteria for baseline funding and the scoring components for workload funding. Baseline funds will be distributed equally among states, while workload funding will be based on each state’s rural facility and population score as well as their technical score. Evaluators will score technical factors based on state policy actions and initiative-based plans for each state.

The technical factors, and the weighting of these factors, in the RHTP application are not just neutral scoring mechanisms; rather, they are closely linked to the Trump Administration鈥檚 health policy priorities.

Weighting Structure: The RHTP funding is split evenly between baseline funding (50%) and workload funding (50%). Although baseline funding ensures all states receive support, the workload funding is directly tied to technical scores that reflect how well a state鈥檚 plan aligns with federal objectives and demonstrates readiness to implement transformative change that furthers federal objectives.
Scoring Criteria: Technical factors, such as rural population share, facility density, hospital financial status, scope of proposed activities, administrative capacity, stakeholder engagement, evaluation framework, and especially alignment with federal priorities, all contribute to the overall score. States that have already adopted or are willing to adopt federal policy priorities are positioned to score higher and receive more funding.
Annual Recalculation: CMS will recalculate each state鈥檚 technical score and workload funding annually to incentivize ongoing alignment with federal priorities and measurable progress toward transformation goals.
Alignment with Federal Priorities: One of the explicit scoring factors is 鈥淎lignment with Federal Priorities,鈥� which measures the degree to which a state鈥檚 plan supports CMS goals for rural health transformation and sustainability. Under the Trump Administration, these priorities may include promoting value-based payment models, encouraging technology adoption, advancing adoption of Supplemental Nutrition Assistance Program (SNAP) food restriction waivers that prohibit the purchase of non-nutritious items, availability of integrated care plans for the Medicare-Medicare dually eligible population, reporting of full Medicaid T-MSIS data, and align policies with federal guidance on short-term limited duration insurance plans.

Preparing for What Happens Next: Implications for States, Providers, and Health Plans

The RHTP offers a rare opportunity to reshape rural healthcare. But success will require strategic coordination and a commitment to long-term change. States in the short and long term should consider include:

Identifying stakeholders who will be involved: Hospitals, rural health clinics, federally qualified health centers (FQHCs), behavioral health providers, and community organizations must be part of the planning process.
Reexamining priorities: States will need to reconcile competing needs across regions and provider types, balancing infrastructure investments with service delivery redesign.
Understanding infrastructure needs to support their project: Technology, workforce, and models of care must be strengthened to support long-term transformation.
Designing evaluation frameworks: States must include robust performance monitoring and reporting mechanisms to meet CMS expectations and secure future funding.

Providers and other stakeholders should also prepare to align with state strategies. Examples include:

Participating in regional partnerships
Adopting new care models and payment arrangements
Investing in technology and workforce development
Contributing data and insights to support evaluation efforts

The scoring structure also incentivizes states that may not yet be fully aligned to implement new initiatives or make policy changes that would improve their technical scores and secure greater funding. States and their partners will need to be united on the goals and initiatives, disciplined about implementing and evaluating the plans based on data informed reports, nimble and willing to make strategic pivots based on feedback and experiences.

Connect With Us

States that are already aligned with Trump Administration priorities鈥攕uch as those with established value-based payment models, short-term limited duration plan options, preferred technology infrastructure, or strong rural hospital support policies鈥攁re positioned to be rewarded in the scoring and funding process.

黑料不打烊 (黑料不打烊), is actively supporting states in developing compliant and compelling RHTP applications. Our advisory services include:

Strategic assessments and stakeholder engagement
Program design and grant writing
Implementation support and technical assistance
Actuarial support
Evaluation and performance monitoring

We help clients navigate the complexities of federal funding, align transformation goals with community needs, and build sustainable models for rural care delivery. For details about the RHTP, including the 黑料不打烊IS State Action Tracker, contact 黑料不打烊 experts below.

Federal Shifts and the Potential Impacts on Healthcare Quality Oversight

Read Blog

This week, our听In Focus听section explores how recent federal shifts鈥攑articularly under the Trump Administration鈥攁re reshaping healthcare quality oversight. 黑料不打烊 (黑料不打烊) has published several analyses on the 2025 Budget Reconciliation Act (H.R. 1, formerly known as the One Big Beautiful Bill), Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), and the 2025 Centers for Medicare & Medicaid Services (CMS) Quality Conference. Together, these federal changes and the policy priority shifts described at the Quality Conference, have implications for monitoring and oversight of healthcare quality for publicly insured, commercially insured, and uninsured individuals.

In this article, 黑料不打烊 experts highlight potential areas for state Medicaid programs, healthcare organizations, and other industry partners to watch for as the rollout of new policies and programs begins to affect programs that monitor quality and creates the imperative to develop new oversight mechanisms.

Overview of Key Federal Policy Shifts

2025 Budget Reconciliation Act/H.R. 1

In July 2025, President Trump signed H.R. 1, the sweeping budget reconciliation legislation that directly affects publicly financed health coverage. Notable policy changes with quality implications include:

Mandatory six-month redetermination and community engagement for select populations
Stricter rules on healthcare-related provider taxes and state-directed payment policies
Elimination of Affordable Care Act (ACA) subsidy eligibility for certain lawfully present immigrants
An end to conditional eligibility for ACA subsidies, as well as passive re-enrollment
Required compliance with community engagement and work policies

Personal Responsibility and Work Opportunity Reconciliation Act of 1996

On July 10, 2025, the US Department of Health and Human Services () and other agencies, redefined 鈥渇ederal public benefits鈥� to exclude individuals with 鈥渦nsatisfactory immigration status鈥� from certain healthcare programs. Examples include Certified Community Behavioral Health Clinics (CCBHCs), Community Health Centers/Federally Qualified Health Centers (FQHCs), grant-funded programs administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), and Title X Family Planning.

2025 CMS Quality Conference

During the 2025 , Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz and senior CMS officials, emphasized CMS鈥檚 and HHS鈥檚 evolving priorities under the Trump Administration. Notable priorities include empowering patients with data, reducing waste and tackling fraud, focusing on prevention, and transitioning to digital quality measures.

Quality Oversight Impacts

Key impacts on quality monitoring programs resulting from these federal changes and evolving priorities include:

Budget constraints elevate monitoring and value-based care metrics. Reduced Medicaid funding and tighter payment rules heighten the need for real-time monitoring of value-based care metrics to ensure financial sustainability in the changing market, optimize reimbursement.

Enrollment changes challenge quality tracking. Tighter eligibility and enrollment policies are expected to decrease enrollment in Medicaid (particularly among the adult expansion population) and the Affordable Care Act Marketplace program. Frequent redeterminations may cause coverage gaps and churn, distorting quality measure denominators and complicating performance tracking 鈥� especially for preventive and chronic care metrics.

Specifically, as the population mix in publicly funded programs changes or as gaps in enrollment exceed the 30鈥�45-day continuous enrollment criteria for many quality measures, the eligible population/denominators of quality measures will likewise fluctuate. Populations that lose coverage or churn on and off eligibility rolls can result in differential impacts for various quality measures (e.g., healthier individuals losing coverage affects prevention measures more than measures of chronic disease care).

Although performance on value-based care quality measures will have increased importance, the ability to track and trend performance will be increasingly challenging. Healthcare organizations will benefit from forecasting potential changes to patient mix and volume and real-time monitoring and improvement opportunities.

Rise in uncompensated care requires new quality monitoring. H.R. 1 changes that reduce eligibility, paired with PRWORA changes that limit treatment for certain individuals who receive public benefits, are likely to lead to increases in the uninsured population and inhibit access to preventive care. These populations tend to use emergency departments more often for health issues that could have been treated earlier or more effectively in outpatient settings, yet quality oversight is limited for populations that receive care outside of publicly or commercially funded programs. New mechanisms for quality oversight鈥攁nd funding of those mechanisms鈥攚ill be needed to monitor the health of these populations.

New programs and priorities warrant updated monitoring. H.R. 1鈥檚 Rural Health Transformation Program and CMS鈥檚 dual-track quality measurement approach (鈥渢reating illness鈥� versus 鈥渕aintaining health鈥�) necessitate a reevaluation of current metrics and monitoring systems.

Implementation of digital quality measures will support these efforts when fully implemented. The accelerated movement toward digital quality measurement and interoperability may create an imperative for healthcare organizations to make the shift. For example, the transition to digital quality measures will be necessary to ensure real-time oversight and improvement of quality measures, population health analytics, maximizing value-based care payments and efficiencies needed to effectively respond to federal changes. At the same time, healthcare organizations will need strategies to effectively deploy digital quality and interoperability within and across their organizations to not just comply, but to maximize their capabilities.

Connect with Us

黑料不打烊 works with state agencies, payers, health systems, and providers to assess and implement quality systems, value-based care programs, performance improvement and digital health. To discuss how federal changes will affect your organization鈥檚 quality programs, contact our featured experts below.

What Should Quality in Healthcare Really Mean Today?

Listen Now

Quality is a word we all use in healthcare, but what does it truly mean for patients, clinicians, and systems striving to improve care? In this episode of Vital Viewpoints on Healthcare, Sarah Hudson Scholle, Principal at Leavitt Partners, an 黑料不打烊 company, and a nationally recognized expert in healthcare quality unpacks how quality has been defined and measured over the years, why measurement sometimes gets in the way of improvement, and how digital interoperability will more accurately capture true drivers of quality. Sarah also shares why engaging patients in defining their goals and outcomes is essential to creating measures that reflect what really matters in people鈥檚 lives.

What鈥檚 Next in Quality: CMS Conference Highlights and Stakeholder Imperatives

Read Blog

This week, our In Focus section covers the 2025 . The event convened healthcare leaders, clinicians, researchers, and patient advocates to explore strategies for improving outcomes and modernizing service delivery. Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz and senior CMS officials emphasized the agency鈥檚 evolving priorities under the Trump Administration, with a strong focus on digital transformation, patient empowerment, and fraud prevention.

In this article, 黑料不打烊 (黑料不打烊) experts highlight key themes from the conference. We note where these themes align with the agency鈥檚 recent proposed rules and requests for information (RFIs), including several RFIs included in the 2026 Medicare Physician Fee Schedule (PFS) , with comments due September 12, 2025. Finally, they advise healthcare organizations of the immediate need to evaluate their risks and opportunities in this digital health ecosystem.

Key Themes of the Conference

Empower Patients with Data

CMS leaders shared a vision for enabling Medicare beneficiaries to experience healthcare technology in the same way that they use in banking and streaming services. Within a year, CMS committed to enabling real-time digital communication with beneficiaries, becoming the nation鈥檚鈥渂est payer.鈥� Notably, a patient safety advocate challenged CMS to think about bi-directional data exchange where patients should be able to share data with CMS.

Subsequent to the conference, Administration officials announced elements of the infrastructure, including conversational AI tools, diabetes and obesity management platforms, and efforts to 鈥溾€� by simplifying data access for patients and providers.

Reducing Waste and Tackling Fraud

The conference coincided with the federal government鈥檚 multi-billion dollar , underscoring CMS鈥� to curbing waste. CMS officials highlighted several aspects of CMS鈥� work, including application of predictive algorithms dubbed 鈥渢he Netflix model鈥� to identify suspicious billing patterns. They also talked about the new CMS Innovation Center model鈥攖he Wasteful and Inappropriate Service Reduction () Model鈥攖o engage technology companies to improve prior authorization processes in traditional Medicare, particularly for high-risk items like skin and tissue substitutes.

Focusing on Prevention

CMS tied the Make American Healthy Again (MAHA) agenda to quality measurement reform. CMS officials encouraged moving to two distinct sets of quality measures: one for treating illness and another for maintaining health. These measures could focus on preventing or delaying onset of disease and on measuring outcomes.

Moving to Digital Quality

CMS also emphasized its commitments to digital quality measurement and interoperability through the adoption of Fast Healthcare Interoperability Resources (FHIR庐) application programming interface (API) technology. For example, CMS鈥� Center for Clinical Quality and Standards is testing a FHIR-based assessment tool for inpatient psychiatric hospitals. Separately, the Centers for Disease Control and Prevention (CDC) is transitioning National Healthcare Safety Network鈥檚 measures to FHIR.

Policy Connections: From Conference Themes to Federal Action

The conference themes reflect and preview broader federal policy changes including:

The 2026 Medicare Physician Fee Schedule (PFS)听听includes multiple requests for input on streamlining quality measures, enhancing chronic disease management, and expanding digital infrastructure.听听
On July 30, CMS announced an updated voluntary blueprint for modern health data exchange,听which encourages healthcare organizations to become CMS-aligned听networks. The agency鈥檚听听describes the voluntary criteria for CMS-aligned in areas of听Patient Access & Empowerment,听Provider Access & Delegation, Data Availability & Standards Compliance, Network Connectivity & Transparency, and Identity, Security & Trust.听听

The Road Ahead for Healthcare Organizations

Healthcare organizations need to prepare for a future regulatory environment that is significantly more digital, interoperable, and chronic disease鈥揻ocused. CMS is building the highway that will enable healthcare organizations to build and maintain the technology necessary for these new initiatives.

This will require state and local government, healthcare organizations, and other partners to retool their infrastructure and workflows to optimize needed operational transformations. All entities should have a strategic roadmap for obtaining and using interoperable clinical data for care management, population health and quality, among other use cases.

Payers will benefit from initiatives such as:

Exploring strategic partnerships to help accelerate technology advancement, such as digital identity providers and specialists in digital quality measurement听听
Exploring ways to increase focus on prevention, such as increasing uptake of the Medicare Annual Wellness Visit or considering new payment approaches for services like medically tailored meals听
Staying current on AI tools and predictive analytics that identify individuals at risk for preventable conditions and working with their provider networks to intervene early听

States can take steps to prepare, including:

Exploring strategic partnerships to help accelerate technology advancement, such as digital identity providers and specialists in digital quality measurement听听
Assessing the reach and impact of existing primary prevention programs to understand how they can use their levers to incentivize healthy lifestyles, encourage culturally responsive health education, and address root causes of preventable illness and disease听听
Identifying opportunities for aligned efforts and referral pathways, including with community organizations, to address upstream health factors听

Health systems and providers will need to reimagine the care experience by:

Exploring early adoption of AI tools for medical documentation to improve both patient experience of care interactions and coding accuracy to support digital quality measurement听
Developing age-tailored checklists to ensure face-to-face time with patients to identify and support top primary prevention goals听
Evaluating and working with their patients to use digital tools that support chronic disease prevention, such as diabetes and obesity management platforms听

Connect with Us

The CMS Quality Conference signaled a substantial shift toward streamlined regulatory approaches and expanded standard data exchange, digital quality reporting and measurement, and AI deployment in care settings and by payers. Stakeholders should anticipate additional federal guidance updates, including in the Medicare Physician Fee Schedule final rule in the fall.

黑料不打烊 works with state agencies, payers, health systems, and providers to assess and implement digital health, quality systems, and information technology. We can help stakeholders develop cross-sector alliances, and organizations plan for and implement changes needed to react to these new initiatives. To discuss the implications of the Administration鈥檚 efforts in prevention, healthcare quality, and interoperability, contact our featured experts below.

Webinar Replay – Digital Quality Measures: Opportunities to Electronically Share Digital Quality Measurement Data With Stakeholders

Watch Now

This webinar was held on July 16, 2025.

As federal and state governments continue to evolve regulations and reimbursement models, healthcare providers are under increasing pressure to do more with fewer resources. Digital innovation, particularly through digital quality measures or dQMs, is a key strategy for easing administrative burdens while enhancing care delivery. This webinar explored how emerging policies and regulations are shaping the digital quality landscape鈥攁nd what healthcare organizations can do now to prepare for continued transformation.

Learning Objectives:

Understand the current and emerging federal and state legislative landscape impacting digital quality measures and their role in shaping healthcare operations.
Identify key benefits and challenges of implementing digital quality measures, including their potential to reduce administrative burden and support real-time data sharing.
Explore actionable strategies for healthcare organizations to proactively align with evolving mandates and leverage digital quality measures to improve outcomes and remain competitive.

Featured Speakers:

Eric Schneider, MD, M.Sc., Executive Vice President, Quality Measurement and Research Group National Committee for Quality Assurance (NCQA)

How National Mandates in Digital Health & dQM are Transforming Healthcare

Read Blog

Digital quality measures (dQM) are quickly emerging as a cornerstone of healthcare operations, propelled by federal efforts to enhance efficiency, interoperability, transparency, and real-time data sharing. New bipartisan proposals like the Healthcare Efficiency Through Flexibility Act (H.R. 483) highlight just how quickly the legislative landscape can change.

Healthcare organizations face mounting pressure to do more with less. As legislation continues to evolve at both federal and state levels, digital innovation remains a critical, key strategy for driving efficiency and reducing administrative burden.

National mandates, emerging legislative proposals, and regulations continue to set the 鈥渞ules of the road鈥� for healthcare, including digital quality transformation. New bills can significantly reshape reporting requirements, data standards, and reimbursement models, often on accelerated timelines. Organizations that proactively adapt to these shifting mandates will be better positioned to improve patient outcomes, streamline operations, and remain leaders in this evolving market.

Foundational Legislation

21st Century Cures Act (2016): Enacted by the U.S. Congress, this laid the groundwork for modernizing the healthcare data ecosystem using application programming interfaces (APIs). Healthcare related provisions focused on interoperability & usability of electronic health data by preventing information blocking (unreasonable interference with access/ exchange of electronic health information); required certified electronic health records (EHRs) to utilize Fast Healthcare Interoperability Resources (FHIR)-based APIs to promote patient access to their health data.

The Centers for Medicare & Medicaid Services (CMS) Interoperability & Patient Access Final Rule(CMS-9115-F) (2020): Required CMS-regulated payers (Medicare Advantage, Medicaid, Children鈥檚 Health Insurance Program (CHIP), Qualified Health Plan (QHP), and Federally-facilitated Exchanges (FFEs) beginning on or after January 1, 2022, to offer FHIR-based APIs for Patient Access and Provider Directories.
- Mandated Payer to Payer Data Exchange for patients to take their data with them if they change payers.
- Promoted data exchange by requiring hospital participation in sending patient event notifications through an ADT (Admissions, Discharge and Transfer) feed.
- Publicly reporting providers who do not list their digital contact information in the National Plan and Provider Enumeration System (NPPES).
- Further curtailed information blocking by publicly reporting eligible clinicians and hospitals who may be blocking information.

Subsequent federal communication in December 2021 formalized CMS鈥檚 decision not to enforce certain provisions of this rule to give payers additional time to comply.

Health Data, Technology, and Interoperability (HTI-1): Certification Program Updates, Algorithm Transparency, and Information Sharing-Final Rule (2024): This rule, which was issued by the Office of the National Coordinator (ASTP/ONC)[1] introduces significant changes to software supporting care. It implements the Cures Act鈥檚 EHR Reporting Program, requiring transparent reporting on certified health IT metrics. It also updated information blocking regulations to make data easier to share. In addition, it established a new standard data model for all 鈥渃ertified鈥� Health IT products: the United States Core Data for Interoperability (USCDI) version 3, starting January 1, 2026. In addition, the voluntary certification program (which has been adopted by 96% of all EHRs) has updated its standards, criteria, and requirements, including standardized FHIR APIs, electronic case reporting using Health Level Seven International Clinical Document Architecture (HL7 CDA) and FHIR-based specifications, revised decision support intervention criteria, and new functionality for patient Electronic Health Information (EHI) restriction requests.
CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F) (2024): Builds on previous CMS efforts and the 2020 CMS Interoperability & Patient Access Final Rule to improve access to and exchange of health records among patients, providers, and payers. It also focuses on simplifying and modernizing prior authorization processes while expanding data-sharing requirements to reduce administrative burdens. Impacted payers must begin implementing certain measures by January 1, 2026, while most API-related requirements are extended until January 1, 2027, based on stakeholder feedback provided to CMS.

Beyond federal legislation, other influential entities like CMS, National Committee for Quality Assurance (NCQA), and ASTP/ONC, are adopting new frameworks that accelerate the shift to digital quality measurement.

Rapidly Evolving National Healthcare Frameworks & Healthcare Quality Landscape Changes

CMS National Quality Strategy/Meaningful Measures 2.0 and CMS Digital Quality Measurement Strategic Roadmap (Published in 2022)

These frameworks map out a future in which interoperability and digital measures play a pivotal role in improving care quality and outcomes.

NCQA鈥檚 Shift to Digital Healthcare Effectiveness Data and Information Set (HEDIS)庐 Measures:
NCQA has taken a significant step in its quality measurement strategy for health plans. Specifically, HEDIS measures are moving to fully digital by 2030, signaling an industry-wide move toward automated data capture and reporting (published in 2024). In addition, they have also launched their Digital Content Services (DCS) product which allows organizations to submit their quality measures digitally for the 2024 measure year.
Digital Quality Implementers Community:
In 2024, a collaborative consensus-based effort was initiated to develop, advance, and standardize tools and platforms that make digital quality measurement possible using open standards instead of proprietary tools. This group is actively working to advance a quality enablement layer including tools, guidance, and standards changes. Leavitt Partners, an 黑料不打烊 company, facilitates this community.

Signals from the Trump Administration Related to Digital Quality

There is ongoing speculation about how the Trump Administration and Congress will approach digital healthcare transformation鈥攑articularly in areas like digital quality measurement. Yet multiple indicators suggest they will stay on this course, and perhaps even accelerate the adoption of digital quality measures.

One key signal is that Ryan Howells, a Principal with Leavitt Partners, an 黑料不打烊 Company, is reportedly one of two finalists under consideration for the position of Assistant Secretary for Technology Policy (ASTP). Known as a champion for digital healthcare data, Howells leads the CARIN Alliance, a national group focused on improving health data access. The ASTP/ONC has significant influence in shaping federal regulations for electronic health records and broader data, technology, and artificial intelligence strategies within the Department of Health and Human Services (HHS).

Additionally, recent bipartisan legislation introduced in January 2025 further underscores a commitment to pursuing digital quality transformation as a linchpin for success in a 鈥渄igital-first鈥� environment, one that prioritizes efficiency and enhanced patient outcomes.

H.R. 483: Healthcare Efficiency Through Flexibility Act

Proposes delaying electronic clinical quality measures (eCQM) adoption until 2030, citing the need to reduce provider burden and pilot more advanced, interoperable reporting tools, including digital quality measurement.

Meanwhile, the national shift toward dQM continues to gain momentum. With eCQM mandates set to begin in reporting year 2025 for Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs), many organizations view these requirements as redundant and burdensome, given the industry鈥檚 rapid move toward fully digital quality. Unlike eCQMs, dQMs leverage more robust structure and standardization, especially through FHIR-based APIs, to enable broader, more timely, and more efficient data capture. The result is a faster path toward high-impact quality measurement and improvement in our increasingly digital healthcare environment.

Major Implications for Healthcare Organizations

Compliance Deadlines:
Evolving Administration rules can quickly shift timelines, significantly impacting prior authorizations, data exchange, and quality measurement.
Financial & Legal Risks:
Non-compliance may lead to financial penalties, legal actions, or even program exclusion.
Workforce Readiness & Capacity:
Requires strategic communications, robust change management efforts, and advanced technology infrastructure.

Strategic Recommendations

Cross-Functional Collaboration:
Engage compliance, IT, clinical, and legal teams to track and adapt to new rules.
Stay Flexible:
Monitor Congress, CMS, ONC, and other federal notices regularly, as new bills and guidance can rapidly change targets.
Technology Assessment:
Evaluate interoperability, API readiness, and EHR workflows to identify gaps.

Need a Tailored dQM Strategy?

Contact 黑料不打烊 for best practices, policy insights, and a customized roadmap for your organization.

Learn more about 黑料不打烊鈥檚 approach to dQM.

[1] ONC was renamed to the 鈥淎ssistant Secretary for Technology Policy/Office of the National Coordinator (ASTP/ONC) in 2024, but in the current administration, may be folded back into CMS.

Digital Quality Measurement: A Key Driver to Value

The healthcare industry is on the cusp of a seismic shift in how quality data are collected, analyzed and reported. Beginning in January 2027, new federal interoperability and prior authorization rules will require widespread data exchange, paving the way for full digital quality measurement (dQM) by 2030. This move toward dQM presents enormous opportunity to enhance quality outcomes, strengthen value-based arrangements, and streamline operations. However, it also requires substantial strategic, operational, and technological changes that most organizations simply cannot manage alone.

Regulatory Mandates

Organizations that delay preparing for the 2027 rule risk costly setbacks and non-compliance.

Opportunity for Transformation

dQM drives efficiency and quality improvement, supporting population health initiatives, care coordination, and value-based contracting.

Complexity and Risk

dQM implementation spans multiple departments鈥擨T, quality improvement, analytics, legal, and more鈥攃reating a host of challenges requiring specialized expertise.

Competitive Advantage

Early adopters will have a first mover advantage. This advantage could result in revenue associated with auto-assignment, STARS bonus, value-based purchasing, reduced sanctions and fine, etc.

Why Partner with 黑料不打烊?

黑料不打烊鈥檚 dQM consulting team understands the operational, clinical, and technical dimensions of transitioning to digital quality measurement. Leveraging deep expertise across health plans, provider organizations, and state and federal agencies, we help you plan, implement, and evaluate your dQM strategies at every stage.

1. Speed to Solution

Front-Seat Knowledge: 黑料不打烊, together with Leavitt Partners, an 黑料不打烊 Company, is actively influencing and shaping national conversations on interoperability and digital measures. Our front-line insights mean you gain rapid access to the latest best practices, regulatory updates, and strategic guidance.
Streamlined Roadmap & Implementation: We help you develop a clear, achievable plan of action鈥攕aving you from the pitfalls of trial-and-error by fast-tracking your implementation and monitoring the results.

2. Cross-Department Coordination

Complexity of Transformation: dQM requires alignment across IT, quality, clinical operations, and finance鈥攐ften a monumental undertaking for organizations already at capacity. Robust change management & strategic planning and communications is crucial for success.
Meet Mandated Timelines: Waiting to act can result in financial risk, stressed operations, and missed opportunities to optimize reimbursement.
Manage Risk: Because digital quality measurement is in an emerging phase, organizations face higher levels of uncertainty. 黑料不打烊 mitigates risk by leveraging our extensive experience and industry partnerships.

3. Proven Expertise and Ongoing Support

Full Project Lifecycle: From early planning and strategy development through implementation and evaluation, we stand by you every step of the way.
Value Beyond Compliance: Our team identifies how dQM can drive broader business goals鈥攊mproving population health, care coordination, and value-based contracting performance..

Ready to Transform Your Quality Measurement?

黑料不打烊鈥檚 expert consultants provide the advanced technical, business, and operational skills you need to succeed in today鈥檚 rapidly evolving regulatory landscape. Don鈥檛 let the complexity of dQM derail your strategic plans or burden your teams. With 黑料不打烊 as your partner, you can confidently navigate and optimize your transition to digital quality measurement.

Take the first step toward harnessing the power of digital quality measurement. Partner with 黑料不打烊 to position your organization for success today鈥攁nd well into the future.

Contact our 黑料不打烊 dQM experts to discuss your organization鈥檚 goals and challenges:

Jeff Booth

Principal

Jean Glossa

Vice President, Client Solutions

Ryan Howells

Principal

Mark Marciante

Director

Juan Montanez

Managing Director

Jodi Pekkala

Managing Director, Care Delivery and Quality Improvement

Robin A. Preston

Senior Regional Vice President

Sarah Scholle

Principal

Daniela Simpson

Senior Consultant II

黑料不打烊 partners with Healthcare Association of New York State (HANYS) on webinar series to help organizations with Survey Readiness

Read Blog

In today鈥檚 complex healthcare environment, navigating the scrutiny of regulatory and accreditation bodies like The Centers for Medicare & Medicaid Services (CMS), Department of Health (DOH), The Joint Commission, and Det Norske Veritas (DNV) Healthcare is critical for the success of every hospital and health system. Unexpected surveys, triggered by recertification, validations or even complaints, can occur at any time.

Early this year, 黑料不打烊 partnered with the Healthcare Association of New York State (HANYS) to develop the content for Survey Readiness: Prepare, Respond, Succeed, a 5-part virtual series. 黑料不打烊鈥檚 expert faculty co-taught the sessions. Attendees dove deep into organizational strategies and tactics to prepare, manage and respond to surveyors effectively 鈥� and get the essential skills to excel in survey readiness.

Survey Readiness: Prepare, Respond, Succeed

Virtual Series | April 2 鈥� 30

April 2: Survey readiness 101: Overview and getting started
April 9: Preparation: How to mitigate risk and prepare for upcoming surveys
April 16: They鈥檙e here: Establishing a survey response and management protocol
April 23: Responding to survey findings: How to develop a strong correction plan and knowing your options
April 30: What鈥檚 next: Leveraging survey findings and strengthening organizational quality and compliance

黑料不打烊 helps navigate dQM to improve health outcomes

Download

The healthcare industry is undergoing a seismic shift in how quality data are collected and reported, creating opportunities to use digital quality measures (dQM) to significantly improve health outcomes and efficiency. Starting in January 2027, new federal interoperability and prior authorization rules will promote widespread data exchange, enabling full digital quality measurement. Payers and providers must invest early to be well-positioned to undergo major strategic and operational changes to optimize healthcare data and transform their business processes.

This issue brief explains the federal policies and national changes that make digital quality measurement possible, explores challenges facing the health insurance industry, and highlights opportunities for payers and providers.

Our 黑料不打烊 dQM team helps health plans, providers, health & hospital systems, federal, state and local payers such as Medicare and Medicaid navigate the transformation to dQM and broader interoperability鈥攆rom early planning through strategy development, implementation, and impact evaluation.

How satisfaction impacts Medicare Advantage plans Star ratings听

Read Blog

Medicare Advantage (MA) Star ratings are more than a quality score鈥攖hey shape the financial and operational success of MA plans. These ratings hinge on factors that every plan can impact by developing continuous improvement processes. The Consumer Assessment of Healthcare and Provider Systems (CAHPS) survey, Healthcare Effectiveness Data and Information Sets (HEDIS) ratings, and the Member Retention rate are all significant levers affecting Star ratings.

The importance of member retention rate

Member retention rate is a measure of member satisfaction but also impacts plan scale. One Medicare Advantage (MA) plan typically reports 0% voluntary disenrollment each year. Another plan is reporting 60% voluntary disenrollment. The voluntary disenrollment threshold is currently set at 18% for a 4-star rating and 10% for a 5-star rating on the measure. The average MA plan is losing more than $60 million in Medicare premium annually due to voluntary disenrollments. The voluntary disenrollment measure excludes members moving out of the service area or sponsor-initiated contractions of the service area.

CAHPS survey impact on Star ratings

CAHPS metrics are an important factor in the Centers for Medicaid and Medicare Services (CMS) Star rating system. MA plans need to develop strong companywide focused member experience processes to help them navigate the healthcare delivery system and community resources available. Evaluating the entire member experience from enrollment through access to care, messaging, outreach, customer service, to disenrollment, involves mapping out every member touchpoint, from a population health approach, to ensure the plan has a caring, approachable, supportive, and balanced experience with the member. Opportunities to eliminate frustrative process steps include identifying health related social needs and disparities that provide easier and time-sensitive access to care and services that are essential to increasing member satisfaction and engagement.

Health plans need a process to identify members who are most likely to be dissatisfied due to events and contact these members to understand the needs and resolve issues quickly. A dissatisfying process issue will repeat if not addressed. Understanding what data the health plan should be continually monitoring and the steps to effectively address any issues is essential to increasing trust with members. It is imperative that members get the opportunity to express their concerns to the health plan with the opportunity to resolve issues satisfactorily before they receive a CAHPS survey.

HEDIS and Star ratings

MA plans need to develop focused processes to proactively monitor HEDIS metrics and drive improvement interventions to keep up with the competition. Having a holistic approach to monitoring, understanding the status and what gaps persist, and a year-round strategy for addressing these gaps is essential to being able to focus efforts on improvement.

As the National Committee for Quality Assurance (NCQA) is moving from a hybrid sampled process to an administrative whole population calculation system, it’s essential that MA plans are addressing each measure in its entirety throughout the year. Digital measurement and Electronic Clinical Data Sets (ECDS) measures are increasing with CMS having a goal of interoperability and implementation of digital quality measures by 2030. Changes with CMS Star metric weightings has increased the total percentage that HEDIS impacts the overall calculation.

Partnering with Pharmacy Benefit Manager to improve Stars

Medicare Part D measures are among the most highly weighted measures in the CMS Stars performance program. Having a strong Pharmacy Benefit Manager (PBM) p artner is a necessity for success. Measures include medication adherence for high blood pressure, cholesterol, and diabetes. Successful plans ensure that members have sufficient prescription fills and re-fills to cover 80% of the days during the year. Measures are scored based on the percentage of members in the denominator who are compliant by the end of the measurement year. Member satisfaction with the plan鈥檚 pharmacy program is a key determinant in plan rating by the member and plan retention, impacting other parts of the CMS Stars program, whether Part D is measured alone or as part of an MA-PD plan.

Accelerating Star Rating Performance

The 黑料不打烊 Stars Accelerator Solution offers a comprehensive, results-oriented approach to Star Rating performance improvement that addresses the multifaceted challenges faced by health plans. It examines your plans leadership structure, operational processes, technology, reporting, member-centric engagement, provider partnerships, and develops a strategy for your organization using a data-driven approach for continuous improvement. Multiple 鈥渨hat-if鈥� scenarios are developed that identify top priorities. Measure thresholds that are too far to reach are replaced by measures that are within reach during the final months of the year.

The Accelerator approach includes 鈥渁ll-hands-on-deck鈥� 鈥� care coordination, customer service, network development, marketing, analytics, and others. Accelerator plans introduce provider and member incentives and/or fee schedule adjustments to increase interest. These plans also provide information to providers on those attributed members who have measure gaps to facilitate provider outreach that is coordinated with plan outreach.

黑料不打烊 Accelerator plans experience a reduction in members choosing to leave, attributed more to prevailing cultural changes over time than to enhanced benefits or member rewards. This program is a cultural transformation designed to strengthen star performance. Click here to learn more about the 黑料不打烊 Stars Accelerator Solution鈥檚 capabilities, where you can request a copy of the 黑料不打烊 Stars Accelerator Playbook. Let鈥檚 have a conversation about how your plan can improve member retention for increased star rating and increased enrollment scale.

Watch a replay of Mastering Star Performance: Strategies from the 黑料不打烊 Stars Accelerator Program.

Webinar Replay: Mastering Star Performance: Strategies from the 黑料不打烊 Stars Accelerator Program

Watch Now

This webinar was held on November 13, 2024.

In this webinar, attendees learned the essential methods and practices to enhance Star ratings through the 黑料不打烊 Stars Accelerator program. The session explored how to leverage data analytics to effectively track current star performance and identify areas for improvement. Additionally, it covered stratification techniques that allow for targeted focus on key measure opportunities throughout the year to ensure optimal results.

Learning objectives:

Learn how to implement proven strategies and best practices
Understand how to leverage data analytics to monitor and assess trends
Provide focus areas to measure opportunities and enhance performance

LEARN MORE ABOUT 黑料不打烊’S STAR ACCELERATOR PLAYBOOK

Featured Solutions:

Featured 黑料不打烊 insights:

More insights from our companies:

Insights

黑料不打烊 Insights: Your source for healthcare news, ideas and analysis.

Receive timely expert insights on topics you care about.

82 Results found.

Foundational Legislation

Rapidly Evolving National Healthcare Frameworks & Healthcare Quality Landscape Changes

Signals from the Trump Administration Related to Digital Quality

H.R. 483: Healthcare Efficiency Through Flexibility Act

Major Implications for Healthcare Organizations

Strategic Recommendations

Need a Tailored dQM Strategy?

黑料不打烊 Spotlight

Digital Quality Measurement: A Key Driver to Value

Regulatory Mandates

Organizations that delay preparing for the 2027 rule risk costly setbacks and non-compliance.

Opportunity for Transformation

dQM drives efficiency and quality improvement, supporting population health initiatives, care coordination, and value-based contracting.

Complexity and Risk

dQM implementation spans multiple departments鈥擨T, quality improvement, analytics, legal, and more鈥攃reating a host of challenges requiring specialized expertise.

Competitive Advantage

Early adopters will have a first mover advantage. This advantage could result in revenue associated with auto-assignment, STARS bonus, value-based purchasing, reduced sanctions and fine, etc.

Why Partner with 黑料不打烊?

Ready to Transform Your Quality Measurement?

Contact our 黑料不打烊 dQM experts to discuss your organization鈥檚 goals and challenges:

Principal

Vice President, Client Solutions

Principal

Director

Managing Director

Managing Director, Care Delivery and Quality Improvement

Senior Regional Vice President

Principal

Senior Consultant II

The importance of member retention rate

CAHPS survey impact on Star ratings

HEDIS and Star ratings

Partnering with Pharmacy Benefit Manager to improve Stars

Accelerating Star Rating Performance