Quality Metrics & Stars
Expert articles and analysis related to quality metrics & stars.
AI Summary — Last 7 Days
CMS is pushing specialty VBC deeper into measurable condition-specific performance, with proposed updates to the Ambulatory Specialty Model for heart failure signaling continued emphasis under the Trump administration on episode- and specialty-oriented accountability alongside hospital/surgeon alignment tensions in CJR-X. At the same time, MA and payer-side quality economics are under sharper scrutiny: KFF estimates Medicare Advantage quality bonus payments will exceed $13 billion in 2026, while newly released CMS-required prior authorization data show denial rates varying from 2% to 25% across insurers—raising questions about whether Stars, utilization management, and “high-value” network design are consistently rewarding better care or simply advantaging better measurement and contracting strategies. For ACOs and risk-bearing providers, the week’s throughline is that quality metrics are becoming more consequential and more contested, especially in heart failure, kidney care, and MA network performance, where clinical outcomes, access controls, and bonus payments are increasingly intertwined. [CMS heart failure model updates](https://news.google.com/rss/articles/CBMiswFBVV95cUxOeW96NUttbWc4NGdfcnNsaHl1TklMbmlsQTVGOXFjbTh5ZWk5bHRZNkFXcFRNcElaZmZFTWtvWTU1ZFdiRENyVWh2aV9EX0VjS3dlRVpnWFNUR0tvS0JBenI3VHAwbm
Related Articles
Medicare Will Spend More Than $13 Billion on the Medicare Advantage Quality Bonus Program in 2026
From newsletter: This Week: Prior Authorization Metrics Provide New Insights into Insurer Practices This Week: Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remai...
A look at where Aetna is seeing value-based care success in Medicare Advantage
A look at where Aetna is seeing value-based care success in Medicare Advantage Fierce Healthcare
Medicare for All: The Allure
Last week, Michigan voters chose former Detroit public health director Abdul El-Sayed as its Democratic nominee for its U.S. Senate seat—the latest in a series of wins by Democratic Socialists... The ...
UnitedHealth’s Crisis Deepens: Lawsuit Alleges Medicare Fraud, Algorithmic Care Denials and $237 Million Insider Sales - sahmcapital.com
UnitedHealth’s Crisis Deepens: Lawsuit Alleges Medicare Fraud, Algorithmic Care Denials and $237 Million Insider Sales sahmcapital.com
Medicare Accountable Care Organizations: Clinical Performance for Patients With Heart Failure
UnitedHealth’s Crisis Deepens: Lawsuit Alleges Medicare Fraud, Algorithmic Care Denials and $237 Million Insider Sales
UnitedHealth’s Crisis Deepens: Lawsuit Alleges Medicare Fraud, Algorithmic Care Denials and $237 Million Insider Sales TradingView
Humana teams with Cityblock to support dual eligible, MA low income members
Humana teams with Cityblock to support dual eligible, MA low income members Healthcare Finance News
To finance Reconciliation 3.0, lawmakers should fix Medicare Advantage fraud - yourvalley.net
To finance Reconciliation 3.0, lawmakers should fix Medicare Advantage fraud yourvalley.net
Medbridge, Patient360 join on Medicare quality reporting
Medbridge, Patient360 join on Medicare quality reporting MobiHealthNews
NCQA's first CMO aims to modernize quality measurement for the AI era
NCQA's first CMO aims to modernize quality measurement for the AI era Healthcare IT News