You can use this report to:

• Learn more about each quality measure, how it is defined and why it matters.
• Access national averages and historical trends for over 90 measures of clinical quality and patient satisfaction.
• Compare performance across different products, like Commercial, Medicare and Medicaid.

We will add data for MY 2025 in February 2027, or you can get it sooner through NCQA’s Quality Compass^®.

How to Access the State of Health Care Quality Report

The report is available through this link. You can also find a link to the report on the HEDIS Measures and Technical Resources web page.

• We recommend that you bookmark the page for easy access.
• You’ll need to enter your contact information on a measure page to access national averages for all measures. (You only need to do this once, but if you clear your browsing data, you might need to enter your information again.)
• The information in the report is for internal use only and may not be redistributed or used for commercial purposes.

Watch this video to learn how to access the report.

Better Benchmarking With Quality Compass

NCQA’s Quality Compass provides access to health plan performance, including HEDIS^® and CAHPS^® benchmarks to identify areas for improvement. It features benchmarks at the national, state and regional levels as well as plan-specific results for competitor analysis.

Release dates for Quality Compass 2026 (MY 2025 Data) vary by product line: Commercial on July 31; Medicaid on August 28; Medicare on October 30; Exchange on November 20.

Learn More

• Read our blog Improving HEDIS Performance Through Benchmarking.
• Visit the State of Health Care Quality web page.
• Use NCQA’s Health Plan Ratings to review and compare health plan performance.

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

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Quality Compass^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post New Data Added to the State of Health Care Quality Report appeared first on NCQA.

“The growing prevalence of CKM syndrome and its widespread impact on population health signals the need for a unified framework that integrates prevention, treatment and quality measurement,” says Adrianna Nava, PhD, RN, NCQA’s Applied Research Scientist. “NCQA sees an opportunity to transform CKM care from fragmented, disease-specific management to holistic, patient-centered approaches.”

Our Approach to Evaluating CKM Care

In 2025, NCQA convened three meetings to address the challenges associated with CKM syndrome. The first meeting focused on ways to improve the quality of care for people with chronic kidney disease. The Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework white paper captures the dynamic discussions and insights from this convening.

The second and third meetings reconvened the roundtable participants to discuss ways to improve the quality of care for CKM syndrome. The new white paper, Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability, captures insights from these convenings.

The white paper outlines a comprehensive approach to improving the quality of CKM care and accountability. It explores five key domains essential for transforming CKM care.

1. Defining ideal care, identifying feasible CKM measures and breaking down silos.
2. Clinical integration, risk stratification and life course perspectives.
3. Patient and community engagement.
4. Technology as a driver of CKM syndrome.
5. Payment reform, health plan and health system coordination.

NCQA gathered input from experts representing a wide variety of disciplines: primary care, pediatrics, nephrology, cardiology, endocrinology, internal medicine, epidemiology, pharmacy, geriatrics, nutrition, gastroenterology, lifestyle medicine, nursing, hepatology, diabetes education, informatics and health policy. The convenings also included three patient advocates who provided valuable input based on their personal experiences with severe kidney disease and diabetes.

Key Findings and Recommendations

This report proposes a framework for improving CKM care quality through measurement and accountability. Recommendations include:

• Measure Integration and Alignment. Reduce the emphasis on process-oriented metrics and develop and promote intermediate outcomes like BP, HbA1c and uACR that are aligned with CKM risk stages and can be tracked over time.
• Risk-Based Framework. Use evidence-based tools and risk calculators to guide early detection, prevention and precision management.
• Cross-Specialty Accountability. Embed CKM coordinators, shared care plans and multidisciplinary documentation to align specialties around shared outcomes.
• Patient-Reported Outcome Measure (PROM) Integration. Incorporate PROMs assessing self-efficacy, health outcome goals, treatment burden and quality of life into performance frameworks.
• Technology Modernization. Invest in interoperability, predictive analytics, remote monitoring and automation to support proactive care.
• Social Determinants of Health Focus. Integrate social needs screening, referral tracking and community partnerships to close disparities.
• Value-Based Payment. Link reimbursement to intermediate outcomes and progression metrics that reward health plans and systems for prevention and coordination.

By aligning professional guidelines, technology and payment systems within an integrated CKM syndrome measurement framework, CKM syndrome care can become a coordinated, holistic and equitable continuum. This approach will not only improve patient outcomes; it will also strengthen accountability, reduce healthcare costs and create a foundation that supports active collaboration among providers, health plans and other stakeholders.

“CKM syndrome is one of the most pressing and complex challenges that clinicians, health systems and health plans face today,” says Nava. “The white paper provides an actionable roadmap for developing a CKM measurement framework that supports whole-person care, equity and sustainability.”

The insights and recommendations gathered from these convenings will guide NCQA in shaping a comprehensive quality improvement framework for CKM syndrome. As this work progresses, NCQA is eager to partner with national stakeholders to drive alignment, strengthen community collaborations and build consensus around a CKM-focused primary care framework for the next phase of this initiative.

To get involved in the next phase of this work, please contact Erin Oganesian, AVP, Corporate & Foundation Relations at eoganesian@ncqa.org.

Learn More

• Download the white papers: Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework and Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability.

Acknowledgments

Thank you to our panel of experts for sharing their knowledge and insights. This research is made possible with support from Boehringer Ingelheim and Novo Nordisk.

The post NCQA Releases New White Paper on Improving Quality of Care for Patients with CKM Syndrome appeared first on NCQA.

Re-Thinking Our Approach to Population Health

NCQA’s Wellness and Health Promotion Accreditation and Certification program has been in place for more than a decade, helping organizations design programs that engage people in improving their health. In 2025, NCQA started the Innovations in Wellness and Condition Management Working Group to update the program to reflect best practices and new technologies for evaluating population risk and providing self-management and coaching to help improve health outcomes. This is part of a larger effort to evaluate how high-quality, effective population health services are delivered across NCQA programs.

“As an industry, we have an opportunity to redefine our approach to population health and how we prevent and manage chronic disease,” says Rachel Harrington, PhD, NCQA’s Senior Product Strategist. “We know that 40-60% of the factors that influence a person’s health come from outside the walls of the healthcare system. With limited resources, especially in primary care and behavioral health, it is important to help support people in managing their health, including the use of digital technologies.”

In 2026, NCQA will start shaping these new standards, focusing on evaluating outcomes and supporting confident decision-making on digital health and wellness solutions. This isn’t just a focus for NCQA. “It’s validating to see that our work aligns with the CMS Innovation Center’s new ACCESS model,” says Harrington. “We hope it will motivate organizations to innovate and improve the patient experience.”

Understanding Health Differences Within Populations and Communities

Improving population and community health requires organizations to identify variations in health outcomes, look for the root causes and target solutions to populations and communities. The upstream, structural and personal factors that drive differences in health outcomes are complex and multifaceted—and often require data, investments and partnerships broader than the healthcare system. NCQA’s Accreditations in Health Outcomes and Community-Focused Care give organizations a framework to understand differences and close gaps.

“We’ve updated our program to give organizations more ways to view population and community health and a greater ability to tailor the program to the areas most relevant to the populations they serve,” says Elizabeth Ryder, NCQA’s Assistant Director, Product Management. “For example, disability status is a new population focus for Health Outcomes Accreditation, which complements a new HEDIS^® measure that we introduced in measurement year 2026.”

Listen to our podcast, One in Four: Making Disability a Quality Priority, to learn more about these changes.

Shaping the Future of Primary Care

Primary care is evolving at an astounding pace. NCQA’s Patient-Centered Medical Home Recognition program laid the foundation by providing an operational and quality improvement framework for primary care. Now, we are helping practices advance their relationships with payers and succeed in value-based care.

“We are looking at the next horizon for primary care,” says Jeff Sitko, NCQA’s Assistant Vice President, Product Management. “We have an opportunity to create a best practice, scalable delivery model that provides a blueprint for primary care practices to continue developing their capabilities. We want to work side-by-side with practices to understand what’s valuable and realistic, while also reducing administrative burden.”

Stay tuned for an announcement about our primary care partners. In the meantime, listen to our Quality Matters podcast, What’s New and What’s Next for Primary Care.

Integrating Primary Care and Behavioral Healthcare

People with mental health conditions and substance use disorders are more likely to experience chronic health conditions like heart disease and diabetes. Similarly, people who are living with chronic conditions may struggle with depression or anxiety. Integrated care models that combine behavioral health and primary care can improve access and coordination, leading to better health outcomes.

“We need more care delivery models that support whole-person care,” says Julie Seibert, PhD, NCQA’s Assistant Vice President, Behavioral Health. “Integrating behavioral health and primary care can improve access and coordination of care by meeting people where they are and implementing a ‘no wrong door’ policy when it comes to accessing behavioral health services.”

In 2026, NCQA will continue to promote integration, with funding from the Health Resources and Services Administration, to support Federally Qualified Health Centers and Look-Alike Health Centers seeking NCQA’s Distinction in Behavioral Health Integration.

We’ve also updated our Behavioral Health Accreditation program to strengthen the focus on population health and network adequacy. Read our blog post, Behavioral Health Accreditation Promotes Accountability, to learn more.

Advancing the Transition to Digital Quality Measurement

The transition to digital quality measurement is accelerating as healthcare moves rapidly toward interoperability and real-time data exchange. Most HEDIS measures are available in a digital format, ready for implementation. From building CQL engines to integrating digital measures at the point of care, organizations are making progress and showing tangible results.

“The year 2030 is our north star to become fully digital, and industry alignment is critical for success,” says Tricia Elliott, NCQA’s Vice President, Quality Implementation. “There are three parallel tracks that need to converge for us to continue forward progress: updates to the CMS Digital Quality Measures Roadmap, conversion of data to the HL7^® FHIR^® standard and clarity on the use of USCDI Core versus USCDI QI Core standards. The more we can build alignment, the easier it will be for everyone to do the work we need to do by 2030.”

In 2026, we anticipate broader adoption of digital HEDIS measures, supported by certification and parallel testing. NCQA recently launched a Digital Quality Measure Evaluation Package that includes a sample of digital HEDIS measures and supporting tools to help explore, test and plan your transition with confidence. Our Digital HEDIS Directory highlights how organizations are using NCQA’s digital HEDIS measures to modernize care delivery, drive efficiencies and improve outcomes.

Visit NCQA’s Digital Quality Hub for more resources to support your transition.

Expanding Use of Clinical Data in HEDIS^®

HEDIS is evolving to provide a more complete picture of care for populations, enabled by increased integration of clinical data. In Measure Year  2026, we will implement six new Electronic Clinical Data Systems (ECDS) measures and three measures will transition to ECDS-only.

“While every organization is on its own journey in incorporating clinical data, what remains constant is the trust in a reported HEDIS rate,” says Taylor Musser, NCQA’s Director, Measure and Data Operations. “This is driven in part by the audit requirements holding all organizations to the same expectations for data contributing to HEDIS. While a measure may be new or updated, the HEDIS Compliance Audit^™ helps to ensure an apples-to-apples comparison as HEDIS evolves.”

Read our blog post, HEDIS MY 2026: What’s New, What’s Changed, What’s Retired, to learn more about what you can expect in 2026.

Improving Quality of Care for Patients with Cardiovascular-Kidney-Metabolic Syndrome

NCQA conducted three expert convenings in 2025 to gather insights and help define our quality measurement approach related to Chronic Kidney Disease and Cardiovascular-Kidney-Metabolic (CKM) Syndrome. We are excited to accelerate this work in 2026.

“We’re interested in exploring quality measures that focus on risk assessment and prevention because if you can prevent one of these CKM-related diseases, you can often prevent them all,” says Caroline Blaum, MD, NCQA’s Assistant Vice President, Chronic Conditions and Complex Care. “I anticipate that 2026 will be a year of significant progress as we define our measurement approach and begin testing with real-world data.”

NCQA recently released a white paper that synthesizes what we learned from the convenings and makes recommendations for a holistic approach to the prevention and management of CKM syndrome.

Defining High Quality Diabetes Care

Diabetes is one of the diseases intertwined within the CKM framework. NCQA’s Diabetes Recognition Program recognizes clinicians who use evidence-based measures to provide high-quality care to patients with diabetes. We added three new measures to the program for 2026: Statin Therapy Prescription, Depression Screening and Follow-Up and Continuous Glucose Monitoring (CGM) Utilization. The CGM Utilization measure is the first step toward understanding and quantifying the growing use of this technology.

“The new CGM Utilization measure will help us understand where the technology is being used, which populations are using it and whether there are barriers limiting adoption,” says Emily Hubbard, MPH, NCQA’s Senior Research Associate. “Our goal is to standardize the data to help organizations capture and report on utilization within a defined population of patients with diabetes. This effort will lay the groundwork for NCQA to develop a broader CGM performance measurement approach in the future.”

Learn more about recent updates to the Diabetes Recognition Program, or access the standards in the NCQA store.

Reducing the Administrative Burden of Utilization Management

NCQA continually evaluates its standards and programs to ensure they remain relevant and useful for the industry. This includes reducing administrative burden so organizations can focus on what matters most: providing high-quality, accessible care. Interoperability is the key to transforming cumbersome processes, like prior authorizations.

“In 2026, we will start to see the impact of the CMS Interoperability and Prior Authorization Final Rule, which should make the process less burdensome and more efficient,” says Tsveta Polhemus, NCQA’s Assistant Vice President, Product Management. “NCQA’s revised utilization management standards are tightly aligned with the federal rules, and extend beyond them, as we also include commercial plans. We provide guidance to help plans analyze denial and appeal rates to identify what’s working and what’s not so they can provide a better experience for clinicians and patients.”

Read our blog post, Breaking Down Silos in Utilization Management: A Data-Driven Approach, to learn more about the updates to NCQA’s utilization management standards.

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

HEDIS^® Compliance Audit™ is a trademark of the National Committee for Quality Assurance (NCQA).

HL7^® and FHIR^® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.

The post NCQA’s 2026 Trends to Watch appeared first on NCQA.

The use of digital tools, combining software and hardware technologies to monitor patients remotely, is gaining traction,³ and is proving to be effective at not only managing therapy complications, but also at improving patients’ quality of life and satisfaction.² One such example is the use of Electronic Patient-Reported Outcomes (ePRO), digital tools that let patients report symptoms, side effects and quality-of-life indicators in real time. These tools have shown remarkable promise in oncology settings that can lead to better identification of patients’ needs, improving patient-provider communication, care management, and patient satisfaction, as well as decreased emergency department visits.⁴

At the federal level, in 2023 the Centers for Medicare & Medicaid Services (CMS) launched the Enhancing Oncology Model (EOM), a voluntary, value-based payment model covering Medicare beneficiaries. Lessons learned from a previous model, the Oncology Care Model, led CMS to require the use of ePROs by EOM⁴ participants beginning in performance period 5 (PP5), which corresponds to measurement year 3⁴, to monitor symptomatic toxicities, physical functioning, behavioral health and health-related social needs. Patients submit data via smartphones, tablets, or even voice response systems. The information is then integrated into EHRs, enabling care teams to respond quickly to concerning trends.^4,5

While large hospitals and health systems are often better equipped to implement remote monitoring and use of ePROs for patients, and have the ability to integrate care across specialties, community oncology practices—where most cancer patients get treatments⁶—face unique challenges to ensure integrated, coordinated care. For community oncologists, remote patient monitoring is a scalable way to extend care beyond the clinic. For rural or underserved populations, it bridges the gap between clinic visits and real-world needs, ensuring continuity of care. Data can be shared across teams, improving communication between oncologists, nurses and navigators, and patients report feeling more in control of their care and more connected to their providers.⁶

In a study of a large community oncology practice, the combination of ePRO and other remote monitoring tools demonstrated significant reductions in hospitalizations (39%), emergency department visits and overall cost of care ($1,146 per member per month in average savings per ePRO-monitored patient per month).⁷

The integration of ePROs and remote patient monitoring (RPM) into transitional oncology care represents a shift toward truly patient-centered models. These technologies can empower patients to be active participants in their treatment, reduce unnecessary utilization, enhance communication across providers and improve outcomes across the board.

This blog is brought to you by Johnson & Johnson and the views expressed are solely those of the sponsor.

¹ Patient Satisfaction and Quality of Surgical Care in U.S. Hospitals. Accessed at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4248016/. September 15, 2025

² The association between care integration and care quality, Health Services Research. Volume 59, Issue 6, December 20204. Accessed at: https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.14214. October 25, 2025.

³ Ochsner Chemotherapy Care Companion. Vol. 38, No.3, 2023. Accessed at: www.accc-cancer.org/docs/documents/oncology-issues/articles/2023/v38-n3/ochsner-chemotherapy-care-companion.pdf. September 16, 2025.

⁴ CMS Enhancing Oncology Model ePRO implementation Fact Sheet. Accessed at https://www.cms.gov/priorities/innovation/media/document/eom-epros-fs. September 15, 2025.

⁵ Reflections on the Oncology Care Model and Looking Ahead to the Enhancing Oncology Model. JCO Oncology Practice. Volume 18, No. 10. Accessed at: https://ascopubs.org/doi/10.1200/OP.22.00329#:~:text=One%20of%20the%20primary%20goals,requirements%20and%20drive%20quality%20improvement. September 16, 2025.

⁶ National Cancer Institute. Accessed at: https://www.cancer.gov/research/areas/disparities/chanita-hughes-halbert-clinical-trials-community-access#:~:text=Approximately%2085%25%20of%20cancer%20patients,the%20quality%20of%20their%20care. September 17, 2025

⁷ JCO Clinical Cancer Informatics. Impact of Remote Symptom Monitoring with Electronic Patient-Reported Outcomes on Hospitalization, Survival, and Cost in Community Oncology Practice: The Texas Two-Step Study. Patt, et. Al. Accessed at: https://ascopubs.org/doi/10.1200/CCI.23.00182. October 30, 2025.

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Organization: Group Health Cooperative of South Central Wisconsin

Rating: 4.5 out of 5 Stars

Product Line: Commercial

State: WI

NCQA Health Plan Accreditation Status: Accredited

Group Health Cooperative of South Central Wisconsin’s Quality Story

Group Health Cooperative of South Central Wisconsin (GHC-SCW) is a non-profit, member-owned health plan providing high-quality health care and member-centered service to 70,000 members. As the first HMO in Dane County, Wisconsin, GHC-SCW pioneered a shift in the health care landscape by bringing health insurance and care delivery together.

What does earning a 4.5-star rating from NCQA’s Health Plan Ratings mean to your organization?

Earning a 4.5-star rating from NCQA for our commercial plan is a direct reflection of the commitment to excellence, compassion and constant pursuit of improvement shown by our care teams, administrative staff and every individual who works to serve our members and our community. This achievement highlights the high-quality, safe and compassionate care we provide to our members. Our team understands the meaning and value behind the NCQA rating, supports the efforts that led to this success and proudly celebrates this shared accomplishment.

What strategic priorities guided your journey toward achieving a 4.5-star rating?

Setting targets. We set a goal to reach the NCQA 90th percentile for HEDIS^® measures related to diabetes, hypertension and adult preventive care (e.g., cancer screenings, immunizations.) We also focused on building member trust and providing a positive experience to drive improvement in CAHPS^® scores.

Improving reporting capabilities. We transformed our reporting capabilities to allow department staff to monitor meaningful, real-time data.

Focusing on continuous improvement. These efforts were strengthened by our use of Lean principles and tools to ensure that our work is aligned with delivering better clinical outcomes and a positive member experience.

What unique processes or tools have you implemented to improve patient experience or clinical outcomes?

We are both a health plan and a care delivery system, so our quality teams maintain a close presence in clinics, enabling ongoing collaboration, education and two-way feedback. These relationships drive progress across clinical quality and patient experience initiatives. Clinically, we enhanced awareness of continuous glucose monitors among members and providers, including outreach to eligible members, provider training and piloting the monitors internally to deepen our understanding of how they work. We also strengthened collaborative care practices across clinical teams to better coordinate treatment.

What lessons did you learn that could help other health plans improve performance?

One key lesson is the vital importance of addressing social determinants of health, which play a significant role in closing care gaps. By identifying and actively addressing barriers, we can deliver more effective, equitable care and achieve better outcomes. Another important insight is the value of incorporating member feedback to help shape programs that truly reflect and respond to members’ needs.

How does your organization cultivate a culture of quality?

We place our members at the heart of everything we do, leveraging our integrated care model to deliver personalized, proactive care. Our culture is built on strong collaboration, a commitment to excellence and a mindset of continuous improvement that is guided by Lean principles. This approach empowers our workforce at every level to eliminate waste, streamline processes and focus on delivering the best possible health outcomes. Staff input is highly valued and encouraged, driving initiatives that not only improve clinical outcomes, but also enhance the overall member experience.

What are your next steps to continue improving HEDIS and CAHPS scores?

We will maintain HEDIS and CAHPS improvement as core components of our strategic plan, keeping these metrics aligned with our True North to deliver exceptional quality and service, and ensure ongoing focus on what matters most to our organization and members.

Learn More

Explore the 2025 Health Plan Ratings and find out how we calculate the ratings.

Learn more about NCQA’s Health Plan Accreditation.

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

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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Real-time Visual Notes created by Ink Factory.

On the last day of the Health Innovation Summit in San Diego, NCQA President and Founder, Peggy O’Kane passed the torch to its next leader, Dr. Vivek Garg, marking 35 years of advancing health care quality and charting the course for NCQA’s future.

Here are some highlights from their conversation.

Dr. Garg: I feel like for the last few days I’ve been visiting the house that Peggy built. And it’s been awesome. This community is awesome, this movement you’ve helped to create. How do you feel about this community?

Peggy’ O’Kane: I just find it amazing to be in this role. This conference is usually really good, but this year I think it’s been particularly great. I feel incredibly fortunate to be working with the quality community, with our teams at NCQA, and now with you, Vivek.

Dr. Garg: I know you don’t like to talk about your achievements because you’re always focused on the future, but what are some of your proudest accomplishments?

Peggy O’Kane: We created the first national system of quality measurement. We created an accreditation program alongside employers who were the purchasers of health care. Those are very proud achievements. But the other thing I really feel proud about is that five years ago we decided that quality measurement isn’t working the way it should be. It should be much more embedded in medical practice. What we’re really trying to do with digital quality measurement is to have people look at their numbers and change the way care is delivered. Has it been a perfect journey? No. But have we gotten people’s attention with it? Yes, we have.

Dr. Garg: What do you think we should focus on next?

Peggy O’Kane: I think we need to enlarge the conversation. We are changing quality measures to be more salient, focused on more important issues and less burdensome. These things are going to take a while, but we also have to focus on the larger environment that these quality measures are deployed in. As long as we have such a fragmented delivery system, it’s really hard to identify who is an accountable entity. And when the accountable entity is a small medical practice, that’s pretty hard to measure. So, we need a policy environment that makes it in everybody’s interest to improve quality. We have a crazy reimbursement system in this country. It’s actively working in the wrong direction. We need to speak up and say, if you don’t pay primary care doctors appropriately, we cannot do this work. And if hospitals make more money by having readmissions than the penalty they pay, guess what’s going to happen?

Dr. Garg: Do you have any other advice for me, or the NCQA team, or this quality community?

Peggy O’Kane: We need to be much more intentionally working together. We’re all very busy in our own organizations, but we have a message to carry to the American public, to health policy leaders and to practitioners: We’re with you. We want to make this work.

Dr. Garg: That’s good advice. So, should we flip the table a little bit?

Peggy O’Kane: Yes. I want you to tell us about yourself and why you are coming to NCQA with this heartfelt dedication to quality.

Dr. Garg: Before I was a physician, I was a son. I grew up in a pretty small town in northern New Jersey. My father was a physician and I saw what being a clinician meant to him. My mother suffered from undiagnosed and unmanaged bipolar disorder for decades, and our family experienced a lot of social stigma, lack of understanding and emergent hospitalizations. I think we all have these experiences where we look at the health care journey and there’s so much lost opportunity. It doesn’t have to be that way. We have the science, the knowledge, the therapies, the interventions and the people. They’re just not set up in the right way. Coming to NCQA is an opportunity to take the quality measurement ecosystem forward, to put the insights in front of the people who actually work together to improve health.

Peggy O’Kane: You’ve had a big dose of NCQA for the past couple of days. What are the two or three things that you take away?

Dr. Garg: It’s clear that this community has a plan and a vision, and I want to be fully supportive of the great work that’s been started. As a clinician and someone working with clinical teams, I think patients assume the information is all there for their clinicians, and it’s not. I want to get to the point where producing the insights is not the work. The opportunity to help people improve their health begins at the point of having the insight. I think we can unleash a new wave of meaningful, clinically rich insights that help patients, families and clinicians see if conditions are optimally managed over time. That’s how we can bend the disease curve and the morbidity curve.

NCQA Announces the Quality Forward Fund

NCQA Board Chair, John Glaser joined O’Kane and Dr. Garg to announce the launch of the Quality Forward Fund—a collaborative effort to invest in research, consensus building and initiatives that drive better outcomes.

“This fund will target the areas where innovation is needed most,” says Glaser. “You’ve heard these themes throughout this conference: whole-person care, digital quality measurement and equitable access. It’s about putting resources where they’ll have the greatest impact on patients. In honor of Peggy’s enduring legacy, we’re inviting partners who share our mission to join us.”

Click here to learn more about the Quality Forward Fund.

Join Us Next Year

Mark your calendar for the 2026 Health Innovation Summit, October 4-7, in Atlanta, Georgia!

The post Passing the Quality Torch: Peggy O’Kane and Dr. Vivek Garg Share the Stage at the Health Innovation Summit appeared first on NCQA.

Real-time Visual Notes created by Ink Factory.

As NCQA marks 35 years of advancing health care quality, the focus shifts from how far we’ve come to where we need to go next. What better place to have that conversation than the Health Innovation Summit, where industry leaders gather to discuss trending topics in health care.

NCQA Founder and President Peggy O’Kane moderated a powerhouse panel of visionary leaders—Mark McClellan of the Duke-Margolis Institute for Health Policy, J. Marc Overhage of The Overhage Group and Dana Erickson of Blue Cross Blue Shield of Minnesota—for a forward-looking discussion on the future of quality.

Challenges We Face in Reinventing Quality

The Medicare Advantage market is shrinking.

CMS projects that Medicare Advantage enrollment will fall by nearly 1 million members from 2025 to 2026—the first decline in decades. Large payers are exiting the market, leaving seniors searching for other coverage options.

Despite this trend, Erickson remains bullish on Medicare Advantage. “Beneficiaries like the experience because it provides care coordination and reduces the fragmentation that is so prevalent across our health care system,” says Erickson. “So, we believe it’s a good product and we still see a very bright future.”

Risk adjustment models are leaning towards ‘sick care’ and away from prevention.

McClellan explained that Version 28 of risk adjustment reform took out a lot of codes geared toward prevention and early stages of chronic disease that were being reported in Medicare Advantage plans. Those changes pushed us toward a fee-for-service infrastructure where downstream complications get coded more reliably than early interventions.

“Let’s not pay for the documentation, but for helping people see their risks and then change their risk trajectory,” says McClellan. “We can call it ‘paying for health.’ That’s what it really should be about.”

Technology creates opportunities, but setting priorities can be difficult.

In health care, we create programs for specific conditions, like heart disease or diabetes care, and we make progress. But the question is: How can we scale our efforts across a thousand different conditions and all of the other things we need to prioritize? That’s where we need to start thinking about systems and processes—and the data and technology that can enable large-scale change.

“Thirty years ago, the challenge was to get information into the clinician’s hands, and now we have care teams working in front of computer screens,” says Overhage. “We have data that is increasingly available and interoperable. We’re like 90% of the way there. I think in the next few years, with the right leadership and guidance, these systems will evolve in a way that makes care better for patients and makes our cost structure more sustainable.”

Value-based care has become a contested concept.

“Nobody knows what it is,” says Erickson. Because value-based care is so complex and has so many different definitions, it has been hard to implement—and that has led to disappointment within the industry. Until we reach a critical mass where we move enough of the financial incentive to pay for prevention and primary care, we’re going to get exactly what we’re paying for, which is acute care.

“Trying to do 5% of your operations one way while the other 95% is still being done another way just doesn’t work,” says Erickson. “You’re not changing the way you’re delivering care.”

Let’s Get This Train Moving

In closing, O’Kane asked each panelist to share the one thing we need to do right now to get the quality train moving in the right direction.

Alignment is key, says Overhage. “We need to continue to work on getting better alignment of the value proposition across the industry—that means patients, providers, health systems, health plans and the federal government—because the lack of alignment is going to continue to limit the progress that we can make.”

Erickson would double down on interoperability. “We have all of the technology, but we still haven’t done it right. We have to really commit to data interoperability—and that rising tide will lift all boats.”

McClellan would focus on getting data into the hands of patients. “I would like to see more groups embrace CMS efforts like ‘Kill the Clipboard’ and enable sharing of automated bulk FHIR^® data. We are already heading in that direction with prior authorizations.”

Join Us Next Year

Mark your calendar for the 2026 Health Innovation Summit, October 4-7, in Atlanta, Georgia!

The post Reinventing Quality in a New Era of Care: What Will It Take? appeared first on NCQA.

Organization: Contra Costa Health Plan

Rating: 4.5 out of 5 Stars

Product Line: Medicaid

State: CA

NCQA Health Plan Accreditation Status: Accredited

Contra Costa Health Plan’s Quality Story

Contra Costa Health Plan (CCHP) is the first county-owned and operated health plan in the U.S. It has provided care for over 50 years. It is accountable to the residents of Contra Costa County, and every dollar is reinvested back into services, partnerships and innovations that directly benefit county residents.

What does earning a 4.5-star rating from NCQA’s Health Plan Ratings mean to your organization?

CCHP is extremely proud to earn a 4.5-star rating from NCQA. Being recognized among the top health plans affirms that a locally governed, community-based model can deliver excellent outcomes and experience, particularly for the Medicaid population.

What strategic priorities guided your journey toward achieving a 4.5-star rating?

CCHP’s strategy is centered around three priorities:

• Supporting providers by aligning quality initiatives with what is happening in the provider’s office—where quality truly occurs.
• Investing in data integration to ensure we could identify true care gaps and move toward ECDS reporting.
• Addressing community health priorities, particularly maternal health, behavioral health and preventive care.

These priorities allow us to focus on measures that matter most to our members, such as perinatal care, immunizations and patient experience.

What unique processes or tools have you implemented to improve patient experience or clinical outcomes?

A key strength of CCHP’s model is our integrated delivery system and integrated data infrastructure. As part of a county health system, we share an Epic platform with our public hospital, and participate in Epic’s Care Everywhere HIE and EpicCare Link, which allows us to exchange data seamlessly across our provider network. This ensures that providers have timely access to complete patient information and that CCHP can identify true care gaps, rather than administrative gaps.

For member experience, we extend beyond the clinic walls. As part of the County Health Department, we are deeply embedded in the community, and partner closely with local organizations to address health needs where they arise. We actively participate in outreach events throughout Contra Costa County—from schools and libraries to health fairs, farmers markets and services for people experiencing homelessness. These touchpoints allow us to meet members where they are, connect them to services and strengthen trust between the CCHP and the community.

We have also been proactive in implementing California’s CalAIM program, expanding services that address social drivers of health. Through enhanced care management and community supports, we connect members to housing navigation, medically tailored meals and other non-traditional services that impact health outcomes. This work ensures that our members’ needs are addressed holistically, improving both clinical quality and patient experience.

What lessons did you learn that could help other health plans improve performance?

• Partnership is more powerful than oversight. By positioning ourselves as a supportive ally to providers, rather than just a payer, we have fostered stronger relationships and better outcomes.
• Alignment is key. Success comes from aligning quality measures—understanding which metrics are most meaningful to providers and which are critical for CCHP—and then building strategies that address both.
• Data transparency is essential. Sharing clear, accurate performance data at both the plan and practice level builds trust, highlights true care gaps and drives improvement.

How does your organization cultivate a culture of quality?

As a county-owned and operated health plan, quality is embedded in our mission. Our staff live and work in the communities we serve, and being part of the County Health Department ensures that improvement efforts are closely aligned with broader public health priorities. We foster a culture of quality through cross-departmental collaboration, leadership accountability and active engagement with providers. By sharing performance results transparently, recognizing successes and supporting practices with actionable data, we make quality a shared responsibility.

What are your next steps to continue improving HEDIS^® and CAHPS^® scores?

We are focused on advancing behavioral health integration, particularly in California, where many services are carved out. We work closely with our County Behavioral Health Department on performance improvement projects and on aligning services. We’re also continuing our efforts to address social drivers of health and support holistic member care under the CalAIM program.

Learn More

Explore the 2025 Health Plan Ratings and find out how we calculate the ratings.

Learn more about NCQA’s Health Plan Accreditation.

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

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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This year, almost a thousand commercial, Medicare Advantage (MA) and Medicaid health plans earned a 1–5 star rating from NCQA.

How Do Ratings Work?

Health plans are rated on a scale of 0–5 stars. NCQA considers plans with 4.5 and 5 stars as the highest-rated health plans in the nation. Ratings are based on three types of quality measures:

• Measures of clinical quality from the Healthcare Effectiveness Data and Information Set (HEDIS^®) and the Health Outcomes Survey (HOS).
• Measures of patient experience using the Consumer Assessment of Healthcare Providers and Systems (CAHPS^®).
• Results from NCQA’s review of a health plan’s structure and quality processes (Health Plan Accreditation).

The overall rating is the weighted average of a plan’s HEDIS, CAHPS and HOS measure ratings, plus Accreditation bonus points, if the plan is Accredited by NCQA. The 2025 Health Plan Ratings are primarily based on 2024 performance data, with some MA metrics reflecting 2023 results due to reporting schedules.

Learn more about the Ratings methodology here.

What’s New for 2025?

NCQA added a new HEDIS measure in the 2025 ratings: Language Diversity of Membership (LDM). This measure evaluates whether health plans actively identify and collect data on members’ preferred spoken and written languages, and has an initial scoring weight of 0.5.

You can view all the changes to the 2025 measure list here.

Highlights and Results

This year, 11 plans earned a 5-star rating—more than double the number of 5-star plans from last year—and 55 plans achieved a 4.5-star rating. NCQA observed positive trends in quality measures.

Stronger Transitions of Care in Medicare

• Meaningful year-over-year improvement in transitions of care for Medicare beneficiaries, which demonstrates better coordination and continuity across care settings.

Progress in Chronic Condition Management

• Increases in five of six diabetes-related measures across commercial and MA, and increases in all six measures for Medicaid.
• The most significant improvement was seen in Kidney Health Evaluation for Patients With Diabetes (KED), which experienced an average increase of more than 5% across all three product lines.

Stabilization of Immunization Measures

• An upward trend in adult and adolescent immunization rates, with improvement observed in several measures.
• Stabilization of childhood immunization rates in Medicaid plans, which are declining at a reduced pace compared to last year.

How Can You Use Ratings?

Ratings serve as a national benchmark for health care quality and outcomes, which can support broader quality improvement efforts.

Policymakers and Regulators

• States use NCQA Health Plan Ratings to evaluate and select health plans that provide high-quality care for Medicaid beneficiaries.
• Many states mandate NCQA Accreditation for Medicaid health plans, which requires plans to submit data for scoring in the ratings.
• Ratings can play a strategic role in helping states meet Medicaid and CHIP Quality Rating System goals and stay aligned with CMS Final Rule requirements.
• State and federal programs, including Medicare, use ratings performance data for value-based payment programs to reward plans that deliver superior care.
• Ratings are publicly available on NCQA’s Health Plan Report Card website for industry benchmarking and transparency, allowing states to compare plans and hold them accountable for performance.

Health Plans

• Ratings help plans identify gaps in care and services and can serve as a roadmap for targeted quality improvement strategies.
• Ratings incentivize continuous improvement by highlighting areas of excellence and underperformance.

Consumers and Employers

• Ratings help employers and consumers identify health plans that consistently deliver high-quality care and prioritize member experience.
• Consumers and employers can search for a health plan by name, filter health plans based on criteria (e.g., star rating, location) and compare results across multiple plans for health topics such as diabetes or maternal health.

View the 2025 Health Plan Ratings here.

Fun Fact: In 1995, NCQA released results of its Report Card pilot project, which used audited HEDIS data to assess performance of 21 health plans across 36 performance measures. For the first time, consumers and employers had access to standardized information to help them choose a health plan. The pilot project evolved into NCQA’s Health Plan Ratings.

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

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

The post NCQA Releases 2025 Health Plan Ratings appeared first on NCQA.

Want to know who’s coming to the Summit? View the attendee list (by company name and title) here.

New! Poster Presentations

For the first time, the summit will feature a poster showcase—a spotlight on eight pioneering organizations that are improving health care quality. You’ll meet the leaders driving this critical work, and discover practical solutions to apply at your organization.

Poster presentation topics include:

• Advancing Behavioral Health Equity: Innovative Tools for Data-Informed Clinical Design
• Assessing Healthcare Disparities Using a Recently Developed Health Plan Quality Measures Index
• AI-Powered Predictive Interventions and Hyper-Personalization: A Revolution in Diabetes Care Management
• Data-Driven Strategies to Align Engagement, Results & ROI in Whole-Person Care for Vulnerable Groups
• Improved Transition of Care Guidance for Dually Eligible Populations

Don’t miss this unique opportunity to experience health care quality innovation up close. View all the poster presentations here.

Spotlight Presentations

Explore the future of health care quality innovation with spotlight presentations—dynamic, concise, power-packed talks happening in the Digital Innovation Theater.

Spotlight presentations include:

• Unlocking Quality Performance: Addressing Unmet Needs in Health Plan Care Management
• Lessons Learned on the Road to Digital Quality Reporting
• Trust Matters: Powering High-Quality, Validated Clinical Data
• Don’t Waste Another Day on Manual Gap Closure
• Quality in Sync: Closing Gaps and Boosting Performance With AI
• From Data to Equity: Powering Whole-Person Health Through AI and Integrated Care

View all the spotlight presentations here.

Meet the Experts

NCQA subject matter experts will be available for interactive discussions, offering a unique opportunity to gather insights about NCQA programs.

Join Us in San Diego!

Register today to spend three days with leaders in the quality ecosystem and engage with innovators transforming the health care industry. Book your room at the Gaylord Pacific Resort & Convention Center by September 19 to lock in the NCQA rate.

Groups of three or more enjoy special discounted pricing. Invest in your team’s growth while saving on registration. Please contact us for help with group registration.

The post Connect and Engage at the 2025 Health Innovation Summit appeared first on NCQA.