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Medicare Advantage Star Ratings: The New Patient Experience Imperative for Health Plans


CMS is putting more weight on patient experience measures in its Medicare Advantage and Part D Star ratings. What health plans can do now to improve their ratings.

In May, CMS issued its Contract Year 2021 Medicare Advantage and Part D Final Rule, doubling the weight of patient experience measures used to calculate Star Ratings. The rule also finalized other adjustments, including the calculation of 2021 and 2022 Part C and D Star Ratings to address disruption resulting from the COVID-19 pandemic.

Increasing the weight of patient experience from two to four for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Star Ratings is significant for both health plans and providers. In recent years, CMS has expanded emphasis on patient experience (e.g., 12 months ago this same weight was increased from 1.5 to 2), and the latest final ruling only continues to increase focus and accelerate the significance of patient-centered care and patient experience. Through this move, CMS is now elevating access to care and patient experience to be equal with outcomes measures.

Health plans should act now

With major financial incentives at stake, it is even more essential for health plans and providers to address negative consumer sentiment and put experience front and center. The time for action is now: The new rules for CAHPS scores will impact Star Ratings in 2023, but will be based on care delivered in 2021. Consequently, health plans should drill into all aspects of their members’ experience this year to pinpoint improvement areas in time for next year’s official survey.

Amy Amick

Amy Amick

While CMS opted to not formally conduct the Medicare CAHPS survey in 2020 due to the pandemic, hundreds of health plans still chose to continue to assess the voice of their members. The CAHPS measures that best capture the sentiments of Medicare Advantage health plan members are:

  • Overall satisfaction with the health plan
  • Overall satisfaction with the prescription drug plan (MAPD Only)
  • Overall rating of health care
  • Overall rating of personal doctor
  • Overall rating of specialist visits

Each of these measures contributes to a health plan’s overall Star rating, and, on a national level, each measure’s score increased from 2019 to 2020. While the overall increase is good news, it is critical for each health plan to not just understand their performance and trending, but also know how they compare to other plans throughout the country to stay focused on the ever-moving quality standards.

Plans will need to assess their unique challenges and key drivers of their performance to define the improvement plans that will have the greatest impact on member experiences and Star Ratings. Insurers that are not improving will be left increasingly further behind, as demonstrated again in 2020, where overall scores increased again year over year, setting an even higher standard that will magnify any performance gaps as the higher weights are applied in 2021 and beyond.

Facing new challenges… with the pressure to move quickly

Admittedly, improving patient experience can be tricky, even without the reality of a pandemic. Elevating experience is much more nuanced than leveraging a clinical intervention, and then measuring its effectiveness against a national benchmark. Plus, the current pandemic adds another layer of difficulty for Medicare Advantage plans, whose members are aged 65 and older and often characterized by multiple chronic conditions — the highest-risk groups for COVID-19 complications, according to data from the CDC.

Because so little was known about the coronavirus in March when cases first started spreading in the United States, health plans struggled with how to respond, and scrambled to reengineer workflows to support their care partners. They found themselves having to constantly adjust their messaging around ever-changing guidance on medical protocols and safety precautions such as face mask practices. They also had to adjust payments and workflows to accommodate the surge in telehealth.

Some of this confusion may have affected payer-provider relationships, which are already challenged. In fact, according to a 2019 survey of plans and providers, 35% of health plans and 24% of providers noted that “willingness to collaborate” is their biggest challenge.

Patients are relying on their health plans for guidance and access to care more than ever. Yet some data suggest patients still are not receiving the information and access to care they need. Results of an online survey of 2,000 consumers in May reveal that less than four in 10 (37%) said their health plan has reached out to them with information regarding COVID-19. Nearly 80% of those diagnosed with COVID-19 said their plan had done something to make them question remaining a member, while 70% would switch right now if they could.

Admittedly, navigating life with COVID-19 is new territory. However, the current crisis also offers an opportunity for health plans to demonstrate that they’re more focused on patient experience than ever before.

Raising the bar

With these COVID-19 related concerns in mind, and realizing that independent of the pandemic, CMS has materially increased the weighting of patient experience, health plans and providers will need to leverage a more proactive and nuanced strategy to improve patient experience. This should include:

  • Listening to the voice of health plan members. Asking patients key questions is essential: How do they feel about the care they receive, their access to care, their relationship with their provider and understanding of their benefits? Also knowing how those experiences vary for different cohorts (subsets of your population) is imperative. Clarity on members’ perceptions allows the plan to build cohort specific interventions and programs to drive improved experience for the member and maximizes the impact of the dollars invested to drive change and improvement. Health plans should establish protocols to continually survey member experience, allowing ongoing feedback to improvement plans as they are being implemented, as well as, member reactions to changing market conditions (e.g. the emergence of COVID-19).
  • Stronger communications.The best way to communicate to beneficiaries is by utilizing the preferred method of outreach for each specific member, including newer modalities such as email or text messages or combinations of modalities. Patient engagement applications can help providers define the needs of specific demographics — by layering in factors such as clinical data, level of engagement in their own healthcare, and barriers to care — so they can tailor the message (e.g., flu shot reminders) and modality in the most effective manner.
  • Bolstering information and resources. Look for ways to efficiently enrich members’ understanding of relevant information.For example, COVID-19 related information is craved by many members; adding links to studies in email newsletters, or offering educational webinars, will enable members to learn more about the signs and symptoms of COVID-19 that might manifest. Enhancing web content — for example, chat boxes to health plan home pages — can also encourage members to seek out answers to their most pressing health-related questions or assuage some of their growing concerns.
  • Strengthening telehealth. CMS has approved telehealth as a means for health plans to gather risk adjustment data, and many providers have implemented some form of telehealth solution. The experience that members have during telehealth consultations – for both acute and chronic-care management needs – will be undoubtedly tied to future CAHPS scores. Yet, according to an ongoing national survey of health plan members, only 50 percent of consumers say their health plan offers telehealth – and among those who are aware that their health plan offers telehealth, only 57% are clear about the cost to use it. Furthermore, a recent study showed evidence of a dramatic spike in consumer interest in telehealth in March and April, as the pandemic hit, but indicated consumer interest has reduced substantially since then. If health plans and providers wish to leverage telehealth as a material venue of care moving forward, they need to take strides today to counterbalance consumer sentiment which has waned since the initial outbreak of COVID-19.

Now is an important time for health plans to evaluate their engagement strategies, to ensure patients are receiving the care, information and experience they need. Start with a clear understanding of members’ experiences as a baseline. Then employ action plans targeted at driving meaningful change in the areas most valued by members and most likely to improve the CAHPS measures that contribute to a health plan’s overall Star rating. These health plans will then be poised to not only avoid penalties, but instead benefit from CMS’ dramatic increase in the weighting of patient experience beginning with next year’s Medicare CAHPS survey.

Amy Amick, MBA, is president and CEO of SPH Analytics, which is headquartered in Alpharetta, Georgia.

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