The quiet transformation: from claims-based to hybrid measures.

Healthcare quality measurement is undergoing a significant but often overlooked transformation. While many hospitals are focused on today’s performance metrics, CMS is already laying the groundwork for the next phase of quality measurement—one that blends traditional claims data with clinical information pulled directly from electronic health records (EHRs).

These hybrid measures represent a meaningful shift in how hospital performance will be evaluated. And while the full impact won’t appear in CMS Star Ratings until 2028, the preparation window is already opening.

For hospital leaders, the question isn’t whether these changes are coming. It’s whether their organizations are ready.

The Move Toward Hybrid Data

Historically, CMS quality programs have relied primarily on claims-based measures—data derived from billing records. While this approach allowed for standardized national comparisons, it often lacked the clinical nuance needed to fully understand patient outcomes.

CMS is now beginning to incorporate hybrid measures, which combine claims data with EHR-derived clinical data such as vitals, lab values, and other real-time patient indicators.

The first areas seeing this transition are hospital-wide readmission and mortality measures, which will soon incorporate both administrative and clinical data sources.

This change will allow CMS to:

• Capture a more complete picture of patient health
• Improve risk adjustment and benchmarking
• Identify outcome differences that claims data alone cannot reveal

But it also introduces a new challenge: data readiness becomes inseparable from quality performance itself.

Why This Moment Requires Executive Attention

Several simultaneous changes are reshaping the Star Ratings landscape. Taken together, they create a new reality for hospitals and health systems:

1. A single domain can override strong performance elsewhere

Under the new methodology, the Safety of Care domain has the potential to suppress otherwise strong ratings, meaning performance in one area can significantly influence overall results.

2. Patient mix changes will alter benchmark comparisons

The growing inclusion of Medicare Advantage patients in quality calculations will affect risk profiles, performance benchmarks, and peer comparisons across many measures.

3. Data readiness is now a strategic capability

As CMS transitions to hybrid measures, organizations must ensure their clinical data infrastructure, documentation practices, and reporting workflows are aligned with new measurement requirements.

In short, quality performance will increasingly reflect an organization’s ability to manage and interpret its own data.

A Risk Many Organizations Haven’t Yet Modeled

In our work with health systems, we are already seeing organizations that appear strong under today’s methodology but are projected to experience Star Rating reductions once the new rules are applied.

This risk is not hypothetical—it’s measurable.

Hospitals that have not yet modeled the impact of:

• Safety of Care domain weighting
• Medicare Advantage patient inclusion
• Hybrid measure data requirements

may be operating with an incomplete picture of their future performance.

The Organizations That Will Succeed

CMS has made its priorities clear. The organizations best positioned for the next phase of quality measurement will be those that:

• Anticipate methodology changes rather than react to them
• Develop deeper visibility into their performance data
• Build internal capabilities to evaluate policy changes before they affect ratings

Hospitals that treat quality analytics as a strategic capability—not simply a reporting requirement—will have a clear advantage.

Questions Worth Asking Now

If your organization is asking questions like:

• How exposed is our system under the new Safety of Care rules?
• What impact will Medicare Advantage inclusion have on our outcomes?
• Are we truly prepared for hybrid, EHR-driven quality measures?

Those are exactly the conversations worth having now—while there is still time to influence the outcome. The next phase of CMS quality measurement isn’t years away. The groundwork is being laid today.

If you’d like to better understand how these changes may affect your organization, schedule time with Beth Godsey to review the upcoming methodology shifts and assess your system’s readiness.