You know your members better than anyone. You have the local trust, boots-on-the-ground presence, and mission-driven focus that larger commercial plans can’t replicate.  But when it comes to Medicaid quality improvement strategies and HEDIS measures, you’re competing with quality teams that have dedicated data science resources and unlimited budgets for technology.

Here’s the reality: Medicaid managed care quality metrics aren’t just about compliance anymore. With state withhold programs now tying your capitation payments directly to performance targets, quality improvement has become a financial survival issue. Miss your targets, and you lose funding. Hit them consistently, and you unlock financial advantages that can transform your organization.

But here’s the deeper problem most plans don’t want to admit: Do you actually know which members are in your care gaps? Not how many need mammograms—but which specific members are actually gettable?

Because once you identify members in care gaps, the real challenge begins. Not all members are the same:

• The Persuadable: need the right approach but will respond
• The Self-Directed: will complete care without your help (don’t waste resources here)
• The Complex Cases face multiple barriers and need intensive intervention
• The Non-Engageable won’t participate despite your best efforts

Traditional solutions lump everyone together and tell you to “increase outreach.” That’s not strategy—that’s spray and pray with your limited budget.

What you actually need is actionable intelligence that tells you which category each member falls into and exactly how to engage them effectively. You need to know who, why, how, when, and what for each member—not just that a care gap exists.

The good news? Your community connections give you an edge that no amount of money can buy. With the right approach—one that’s tactical, practical, and built for organizations like yours—you can turn quality improvement from a compliance burden into a competitive advantage.

Watch: See how precision analytics identify and prioritize HEDIS care gaps →

Why It Matters for Community Health Plans (The Real Stakes)

Many states withhold programs are now withholding portions of your capitation payments until you hit performance targets¹. Miss them, and you’re operating at a loss. Meanwhile, the bar for quality performance keeps rising, with increasingly sophisticated strategies becoming table stakes for contract renewals.

The four areas where poor quality performance hurts most:

1. Direct financial impact from withhold programs and reduced reimbursements
2. Contract vulnerability when competing against plans with better metrics
3. Member churn as members migrate to higher-rated plans or are auto-assigned to them
4. Regulatory burden through increased oversight and reporting requirements

The community health plans that survive and thrive won’t be the ones with the biggest budgets—they’ll be the ones that leverage their resources and local strengths most effectively.

See how technology turns HEDIS challenges into competitive advantages →

The Challenges Nobody Talks About (But Everyone Faces)

The “Henry” Problem

Traditional analytics miss people like “Henry”—low claims history but high emerging risk. A 63-year-old in a rural area with transportation barriers and limited technology access might show only $145 in claims this year, but predictive models suggest a 66x cost increase is coming. Generic risk scores miss these nuances because they’re designed for populations with good healthcare access.

Resource Reality Check

You need precision, not scale. The ability to call 100 members and get 10x the performance beats broad campaigns reaching 1,000. You need interventions that work with your existing infrastructure, not against it.

The Trust Advantage

Your members face transportation issues, language barriers, housing instability, and multiple jobs. But they already know and trust your organization. You have community connections no algorithm can replicate.

But trust alone isn’t your full differentiation. It’s your capability to leverage those member relationships with the right method and data—your ability to granularly prioritize which members to reach and what specific message to tell each one. When you combine your natural member relationship advantage with precise, actionable intelligence, that’s where you can outmaneuver your competitors who rely on generic outreach strategies. Meet your members where they are.

See how community health plans turn local trust into better outcomes →

Key Quality Measures That Actually Move the Needle

Understanding which metrics drive the biggest impact on your financial performance is crucial for prioritizing your limited resources.

HEDIS 2025 Priority Areas for Medicaid Plans

High-Impact Measures (focus here first):

• Preventive Care: Cancer screenings, immunizations, wellness visits
  • Do you know which members are persuadable—and what message would actually get them to schedule that overdue screening?
• Chronic Disease Management: Diabetes care, blood pressure control, asthma management
  • Are you reaching the right members before chronic conditions become acute?
• Care Transitions: Medication adherence, follow-up after hospital discharge

  • Do you have a system in place to flag high-risk discharges that lack transportation or housing stability before they bounce back to the ED or are readmitted?

• Behavioral Health: Depression screening, follow-up after mental health episodes
  • Can your outreach distinguish between someone who needs a text, a call, or a warm handoff to a trusted provider?

New for 2025 (prepare now)³:

• Documented Assessment After Mammogram (BI-RADS reporting)
  •  Are your provider partners documenting consistently enough for this measure—or will ECDS expose hidden gaps in your data capture?
• Follow-Up After Abnormal Mammogram
  • Do you have visibility into who actually needs follow-up—and whether they’ve already given up trying to schedule it?
• Blood Pressure Control for Patients with Hypertension

  • Is your team using predictive models to intervene before these members show up in the ER—or still relying on outdated risk scores?

See how to prioritize HEDIS measures by impact and feasibility →

The ECDS Reality Check

By 2029, NCQA plans to phase out the hybrid reporting method, shifting away from manual medical record reviews toward electronic health records and claims-based reporting³. This transition means you need providers who document well and systems that capture data accurately. Start preparing now—plans that wait until 2029 will struggle to hit targets.

STARS Rating Improvement Strategies

 For dual-eligible special needs plans (D-SNPs), Star Ratings provide additional quality performance requirements and financial incentives. The 2025 Star Ratings showed continued industry decline, with only 62% of membership in 4+ star plans, representing a significant decrease from previous years⁴⁵. Meanwhile, we saw nearly half the overall enrollment growth in Medicare Advantage this year came from Special Needs Plans.

Focus on What Counts Most for D-SNP

For D-SNP members, the most important CMS Star Ratings measures are those that directly reflect the unique needs and challenges of DSNP members who typically have a low income, have multiple chronic conditions, and may experience barriers to care such as low health literacy or social instability.  The Star Ratings measures that matter the most for D-SNP members include care coordination and condition management because D-SNP members tend to have multiple chronic conditions and frequent hospitalizations.  These measures include but are not limited to, Transitions of Care (TRC), Statin Use in Persons with Diabetes (SUPD), Controlling Blood Pressure (CBP) and Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC).

Medication adherence for diabetes, hypertension and cholesterol since non-adherence to medication among D-SNP members due to factors such as cost, complexity and access issues is prevalent.

D-SNP members often face social and systemic barriers, so strong member experience and support services like transportation or culturally appropriate aligned care can drive better performance on member experience measures from the CAHPS survey.

And lastly, operational and access measures that can impact retention and satisfaction.  CMS closely monitors how D-SNPs serve vulnerable populations, including those with language or accessibility needs. Operational excellence with D-SNP members at the forefront of decision-making is key for call center, appeals, disenrollment and complaints Star Ratings measures.

The Role of AI in Medicaid Quality Improvement

AI isn’t just a buzzword—it’s becoming essential for survival. As well-resourced commercial plans use sophisticated analytics to compete for your state contracts, community plans without AI will be at a serious disadvantage.

What AI Actually Does for Quality Improvement

AI helps solve the precision problem. Instead of broad campaigns that waste resources, AI identifies exactly which members need which interventions and when.

Three practical applications:

• Risk prediction: Identify members likely to develop expensive conditions before they do
• Intervention targeting: Match specific outreach strategies to member characteristics and barriers
• Outcome tracking: Monitor which approaches work and adjust in real-time

The Community Plan Advantage with AI

Here’s what larger plans miss: AI works better when you have local knowledge and community trust. Generic AI models designed for large populations often miss the nuances that matter in smaller, tight-knit communities.

Community plans that combine AI precision with local insight create interventions that are both data-driven and culturally appropriate—something big commercial plans struggle to replicate.

Watch AI-powered quality improvement workflows in action →

Your Next Steps: Building a Quality Strategy That Actually Works

Quality improvement isn’t about having the perfect system—it’s about making your existing resources work smarter.

The Four-Step Approach

Step 1: Start with What You Have

Don’t overhaul everything. Begin by understanding which of your current quality initiatives are working and which aren’t. Are you seeing consistent patterns in who responds to outreach and who doesn’t? That’s data you can use.

Step 2: Think Precision, Not Scale

A targeted intervention with 100 members often delivers better ROI than a broad campaign reaching 1,000. Focus on reaching the right people with the right message.

Step 3: Leverage Your Local Advantage

You know your community in ways that big commercial plans never will. Partner with local organizations, understand regional health challenges, and design interventions that make sense for your specific population.

Step 4: Measure What Matters

Focus on outcomes that directly impact your financial performance and member health: quality measure improvements, emergency department utilization reduction, medication adherence, and care gap closure.

See how to make this 4-step approach actionable →

Partner Smart

Choose technology vendors who understand your constraints because they themselves have worked in a health plan. Look for vendor partners that can show you exactly how their approach will work with your existing resources and take upside and downside risk. This means the vendor is financially accountable for the outcomes of their services and not just paid for effort or volume. Their payment is tied to performance – they are partners.

Frequently Asked Questions

How quickly can we see results? Most effective quality improvement initiatives see initial insights within weeks, not months. However, meaningful quality measure improvements often take 6-12 months to show up in official reporting, so consistency and early action are key.

How do I know if my current analytics approach is working? Ask yourself: Are you getting specific, actionable recommendations, or generic risk scores? If you’re receiving ranked lists of thousands of “high-risk” members without context about why they’re high-risk or what to do about it, you’re probably not getting the value you’re paying for. Effective analytics should tell you not just who needs help, but what kind of help they need and how to deliver it with your existing resources.

What’s the difference between predictive analytics and prescriptive analytics? Most predictive analytics tell you what might happen. Prescriptive analytics tell you what might happen, why it might happen, and what to do about it. For example, instead of “Member X is high-risk for emergency department visits,” prescriptive analytics provide “Member X is likely to use the ED for primary care needs because they live in a rural area with transportation barriers and have limited technology access. Here’s how to engage them proactively with your existing care management resources.”

We’re already working with another analytics vendor. Can we use both? Absolutely. The best approaches are designed to complement your existing analytics team and solutions, not replace them. Many organizations use specialized tools for specific quality initiatives while maintaining other systems for different purposes.

How do you handle health equity and social determinants of health? Social determinants should be core to any quality improvement model, not an afterthought. Effective approaches don’t just identify that someone is “high-risk”—they explain how factors like rurality, language barriers, transportation access, and technology adoption influence healthcare engagement. This allows you to design interventions that address the barriers members face, rather than assuming all high-risk members need the same type of outreach.

What’s the lift to get started? Most effective quality improvement solutions streamline your current resources rather than adding to your workload. The typical requirements to get started are minimal: eligibility and claims data (in whatever file format you currently have), the team member(s) we’ll work with, and timing of projects. We’ve seen successful projects executed with teams as small as one person. The key is working with partners who understand your constraints and can deliver results without requiring massive organizational changes or additional staffing.

The Bottom Line

Mission alone won’t save you. In today’s environment, community health plans need to combine their mission-driven focus with tactical, data-driven strategies that deliver measurable results.

The health plans that thrive won’t be the ones with the biggest budgets—they’ll be the ones that most effectively leverage their community connections and limited resources. Your mission is your strength. But mission plus precision? That’s how you win.

Ready to see what precision quality improvement looks like? Watch quality gap closure in action → See how community health plans are achieving measurable HEDIS improvements and Star Ratings success.

Talk with experts—former health plan executives who’ve been in your shoes and understand what actually works in community-based settings. Schedule a consultation →

Sources and References

1. North Carolina Department of Health and Human Services. (2025). Quality Management and Improvement. Retrieved from medicaid.ncdhhs.gov
2. Centers for Medicare & Medicaid Services. (2025). Quality Improvement Initiatives. Retrieved from medicaid.gov
3. National Committee for Quality Assurance. (2024). HEDIS MY 2025: What’s New, What’s Changed, What’s Retired. Retrieved from ncqa.org
4. Centers for Medicare & Medicaid Services. (2024). 2025 Medicare Advantage and Part D Star Ratings. Retrieved from cms.gov
5. HealthScape Advisors. (2024). Early analysis: How health plans fared in the 2025 Medicare Advantage star ratings. Retrieved from healthscape.com