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For Health Plans that want Competitive Star Ratings, Deeper Member Experience Insights are Needed

by Richard Hamer

Medicare Advantage is the fastest growing line of health insurance.  Member experience is its most important quality rating domain.  And CAHPS is becoming the most important source of member experience metrics.  Seeing these trends, many health insurers are turning to annual quality rating diagnostic and monthly tracking projects to understand how the interactions between members and health plans might affect future CAHPS survey results. 

Clients who commission a 2021 diagnostic or tracking study before December 31, 2020 improve their budget management and will obtain a discount.

The Medicare Advantage Opportunity.

For health insurers, Medicare Advantage (MA) keeps looking better and better.  The line of business is growing faster than any other and, according to the Center for Medicare and Medicaid Services (CMS) is expected to continue growing at an estimated 11% per year  through 2023.  That translates to a new customer population around 3 million per year.

Besides the growth of the market, MA represents a huge opportunity for health plans to be rewarded for doing well by their members.  The CMS Star Ratings system for assessing how well plans are serving their members triggers bonuses and rebates estimated at $12.2 billion in 2020.  Health plans with higher Star Ratings are able to use their bonus/rebates to offer richer benefits, more supplemental benefits, and some are allowed more marketing opportunities throughout the year.  High Star Ratings give health plan competitiveness a boost that goes beyond the money.  Health plans that cannot compensate for having fewer Stars, will fall into a downhill trajectory because their benefits will not compare favorably to others.

Member Experience Insight Needed.

Star Ratings are the product of many health plan performance domains.  In the Star scoring algorithm, the domain whose weight  has increased over the past years is Member Experience.  According to CMS, by 2023 member experience ratings will rise in weight to account for over 55% of the overall Stars health plans receive.  The source of much member experience scoring is the Consumer Assessment of Healthcare Providers and Systems survey (CAHPS survey).  By 2023, half of the measures increasing in weight will be member experience metrics captured by CAHPS.

The Problem.

Across the health insurance industry, the enterprise required to capture, process, and score metrics for Star Ratings is well developed.  But that investment doesn’t lead to insight as to what occurred during member interactions with their health plans.  For example, a health plan may receive a below average “Overall Health Plan Rating” from its CAHPS survey.  This creates the question as to why.  Efforts by health plans to use existing data from CAHPS and administrative sources invariably fall short of helping health plan management decide which actions will do the most to increase that rating.

The Solution.

For health plans that want competitive Star Ratings, deeper member experience insights are needed to prioritize action.  Deft Research offers a Quality Ratings Diagnostic Service — a fully developed process that flexes with client needs.

Having a developed research process in place reduces client risk because it minimizes the variation in how projects are managed.  A quality ratings project moves through three stages:

  1. Survey development — Deft Researchers work with clients to make sure key hypotheses are tested and information for decision making is produced.
  2. Data collection — through an online or telephone survey usually of clients’ own members; Deft fields the survey and manages the list and responses.
  3. Insights development — Deft produces a driver and other analyses specifically designed to help clients manage their quality improvement program.

A Case Study of How One Client Benefitted

In this case, our client uses an annual quality rating diagnostic survey to understand what lies beneath ratings obtained by CAHPS surveys.  Keeping with the example of the Overall Health Plan Rating, the percentage of members giving our client low ratings had jumped from 15% to 28%.  The client recognized that this will become a problem for future Star Ratings if not effectively addressed.

Deft wrote a survey focused on obtaining details about the member experiences leading to member disgruntlement.  Results are shown below with a summary of the findings:

Report Topics Examples of Results
General Results Communication issues are a top driver of the Overall Health Plan Rating.  These issues were related to the health plan’s COVID-19 response, cost increases, and network limitations.
Care Coordination When doctors did not “always” talk to members about prescriptions, health plan ratings were worse.  Similarly, when test results were later than expected and doctors failed to follow up with them, ratings were worse.
Customer Service Members gave the health plan low ratings when they felt the help understanding coverage was unsatisfactory.
Drug Coverage Surprises in out of pocket costs for prescriptions drove the overall rating down.

The quality ratings diagnostic took the complexity of health plan operations and boiled them down to a manageable set for focus. The results helped the health plan’s management team work together to develop priorities for member experience improvement.  These in turn led to budgets reflecting those priorities.  Because the client has done the diagnostic service for several years, trends in these key areas help them to gauge the effectiveness of their past efforts.