The New Standard Gives Payers the Full Picture for Quality Reporting

For years, health plans have been asked to prove quality with only half the story.

Claims data tells you what was billed. It doesn’t tell you what actually happened in the exam room. It misses the HbA1c result that closes a diabetes care gap, the blood pressure reading that confirms control, and the colorectal screening documented in the chart but never coded.

When HEDIS measures depend on clinical detail that claims can’t capture, scores suffer, chart chases pile up, and quality teams spend reporting season reconstructing care that already happened.

The claims-only model is running out of runway.

For decades, the hybrid method papered over the gap. If claims couldn’t prove a measure was met, plans sampled members, requested records from provider offices, and abstracted the answer by hand. It worked, at a cost: months of retrieval, frustrated provider partners, and a score that reflected the plan’s chase capacity as much as the care members received.

That safety net is being removed. NCQA plans to retire the hybrid reporting method entirely by measurement year 2029, replacing it with Electronic Clinical Data Systems (ECDS) reporting. Measures that carry real Star Ratings weight are on that path, including Controlling High Blood Pressure, Glycemic Status Assessment, and Transitions of Care. Colorectal and cervical cancer screening have already moved.

The direction is clear. The HEDIS MY 2026 technical specifications were reformatted to align with FHIR, and several common measures, including statin therapy for patients with diabetes and cardiovascular disease, are now ECDS-only. NCQA is explicit about what plans should do: reduce manual workflows and increase the availability of structured clinical data.

In an ECDS world, there’s no chart chase to rescue a score at year-end. If the clinical evidence isn’t in your data, then as far as your score is concerned, the care didn’t happen.

Getting clinical data is getting easier. 

Payers didn’t lean on claims because they preferred them. They leaned on claims because clinical data was hard to get: scattered across thousands of provider EHRs, locked in inconsistent formats, and too costly to collect at scale.

That equation has changed. By 2024, 70% of U.S. non-federal acute care hospitals had enabled patient access through apps built on FHIR specifications, according to ASTP/ONC. The standard pipes are in place at most U.S. hospitals, and regulation is extending them further.

Under CMS-0057-F, impacted payers must have FHIR-based Provider Access and Payer-to-Payer APIs live by January 1, 2027. Both must carry USCDI clinical data alongside claims and encounters. For the first time, the infrastructure for exchanging clinical data at scale is a federal requirement, not a pilot project.

Access, though, is only half the problem. ASTP/ONC data shows that most health information exchanges still routinely trade HL7 v2 messages and CDA documents, with FHIR adoption slower. Clinical data arrives in many shapes. Making it usable for quality measurement means normalizing, de-duplicating, and tying it to the right member, every time.

The New Standard: One complete, longitudinal member record.

The New Standard raises the bar for health data interoperability. It brings claims and clinical data together into one complete, longitudinal record for every member.

That record is built on FHIR from the ground up and designed for how payers actually operate. Lab results, vitals, screenings, diagnoses, and encounters sit next to the claims history they explain. They are normalized to a common model and attributed to the right member.

The difference is timing as much as completeness. The old way pieces together a partial view after the fact, usually in a sprint before submission. The New Standard gives you the full picture of every member, ready when you need it.

Quality reporting becomes the starting point, not the finish line.

With a complete picture, HEDIS reporting stops being a year-end reconstruction project. Plans can report accurately and defend their scores with clinical evidence an auditor can trace. More importantly, they can act on the same data all year:

• Get credit for care already delivered. A colonoscopy from six years ago, documented in the member’s chart but never billed to your plan, can close a gap the day the record arrives, instead of waiting on a year-end chart chase.
• Intervene earlier with high-risk members. Clinical signals like an uncontrolled reading or a missed screening surface while care teams can still change the outcome.
• Capture the full acuity of your population. Diagnoses documented in the clinical record support risk adjustment that reflects members’ true health status and holds up to scrutiny.

The financial stakes are real and rising. KFF estimates Medicare will spend at least $13.4 billion on Medicare Advantage quality bonus payments in 2026, up from $12.7 billion in 2025. Those payments go only to plans rated four stars or higher.

That bar is getting harder to clear. Per KFF’s analysis, the share of MA enrollees in bonus-eligible plans fell to 68% in 2026, the lowest since 2018, and contracts at four stars or above dropped from 261 to 209 as CMS raised performance thresholds. When cut points tighten, every measure point lost to missing clinical data costs more.

The chain is simple. Better data drives better care and more accurate risk adjustment. Together, those drive stronger Star Ratings and more revenue from CMS.

Built on FHIR, not adapted to it.

1upHealth didn’t adapt to FHIR. We were built on it.

That foundation is why leading health plans trust us with their most demanding interoperability projects. It’s also why we see what’s possible before the rest of the market catches up.

We push interoperability to the edge as a practice, not a slogan. That means going beyond minimum compliance requirements and turning regulatory infrastructure into a strategic data asset. It means working to connect more clinical sources, normalize messier data, and deliver usable insight faster than anyone else. 

Other vendors move data. We make it complete, trusted, and ready to drive outcomes. Every time the industry raises the bar, we’ve already cleared it, and that’s what makes 1upHealth’s interoperability approach The New Standard.

Claims-only in quality reporting is the old way.

The industry has already decided where quality measurement is going. NCQA is retiring the hybrid method. CMS is mandating FHIR-based clinical data exchange. Fewer plans are clearing four stars. The plans that win won’t be the ones with the biggest chart chase teams. They’ll be the ones that already have the full picture.

Claims-only is the old way. Complete data is The New Standard.

To learn more about how 1upHealth is leading the way with The New Standard, watch our Clinical Data Exchange webinar on demand.