Changes to HEDIS® and CAHPS® Impact Health Plan Member Relationships
What will this mean to payers and their highest risk members?
February 8, 2022

It is a new year; many health plans are implementing new programs & initiatives to improve quality care and experience for their members. Changes to the Healthcare Effectiveness Data and Information Set (HEDIS)® for measurement year 2022 are afoot across Medicaid, Medicare Advantage, and Commercial Health Plans. In addition, Medicare Advantage plans continue to adjust to the measure weighting assigned to Consumer Assessment of Healthcare Providers and Systems (CAHPS)® survey as well as changes to the Health Outcomes Survey (HOS)® measures.

Mom and child at the super market

The Centers for Medicare and Medicaid Services (CMS) continue to encourage value-based care and program design, paying for quality and experience— and measure changes could significantly impact the way health plans and their provider partners engage and interact with patients, especially beneficiaries who need help managing one or more chronic conditions, complicated by social determinants of health (SDOH). 

The recent proposed rule and Advance Notice indicate that future measures of healthcare disparities are on the horizon. For now, HEDIS and CAHPS measures offer new opportunities for health plans to elevate their standards of care, motivate members and engage differently — which could make a big difference in the lives of those who are underserved by traditional approaches. 

What’s Next for Health Plan Quality Improvements

Adjustments to the HEDIS measures, which went into effect on Jan. 1, 2022 demonstrate the quality communities’ commitment to health equity, life quality, and patient-centered care. NCQA introduced race and ethnicity stratifications to five HEDIS measures as a first step to addressing and reducing health disparities. 2024 Medicare Star Ratings (based on calendar year 2022) include an updated Plan all Cause Readmission (PCR) measure and the increase of Controlling Blood Pressure (CBP) to a weight of 3.  

Patient consults with his care provider

Contract Year 2021 Medicare Advantage and Part D Final Rule doubled the weight of CAHPS patient experience measures to 4x weight for calendar year 2021 (Stars 2023). In the last few years, Medicare Advantage plans have seen member experience measures contribute to nearly a third of the total Star Rating.

The aforementioned CY2023 Proposed Rule and Advanced Notices highlighted potential development of “a measure to assess whether plans are screening their enrollees for health-related social needs such as food, housing, and transportation.” Coupled with the race & ethnicity stratification, plans are poised to learn more about their memberships’ needs and must continue to respond appropriately.  

Embracing Changes and Elevating Member Care in Quality Metrics

While CAHPS and HEDIS are not new measurement tools, the changes present new challenges for health plans that have often struggled to reach and engage the members who need the most support. Here are three ways health plans can boost their performance in these areas and improve their relationship with members. 

  • Improve experience through personalized outreach. Members can be difficult to reach and engage. Health plans must utilize all the communication channels available to them, and gain consent to use those channels. Reaching patients through secure, text-based messaging or web chat (when patients do contact their health plan) and other channels is essential to engaging your members.
Example of the Wellthapp

  • Support members with meaningful incentives. While health plans can’t financially incentivize medication adherence for members enrolled in Medicare Advantage plans, they can offer meaningful incentives for activities such as checking blood pressure or blood sugar. These rewards support members’ in accessing concrete needs such as groceries & transportation. One Michigan-based Medicare Advantage plan found that 87% of rewards were redeemed on food, household needs, and clothing. 

  • Encourage the use of digital health apps to support health goals. While mobile apps have increased tenfold over the last three years, not every app is right for every individual. With that in mind, consumers are more likely to use health apps that motivate them, for example, by incorporating guidance from a health coach, or enabling them to check in at regular intervals, or provide them with personalized motivators (i.e., messages from family and friends). One Medicare Advantage plan incentivized members to eat daily healthy meals and take daily glucometer or blood pressure readings as prescribed. Within months of the year-long program, members achieved an average of 96 percent adherence to incentivized tasks. Daily engagement produces cost savings results as well as clinical outcomes improvement.

While measure changes may take some adjustment, health plans that focus on improving member experience, expanding access to care and engaging individuals in new ways will be poised to succeed in 2022.  


HEDIS(R) is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS(R), which stands for Consumer Assessment of Healthcare Providers and Systems, is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).