Medicare Advantage Star Rating Calculations Change; Act Now to Change 2023 Perceptions

Experience, access, and complaints will matter more in future scores; current studies indicate plans currently are not communicating well with members.

Two recent studies indicate that Medicare Advantage plans have room for improvement to satisfy consumers, particularly when it comes to communication. And the situation to ensure members rate plans highly will soon become more challenging. The Centers for Medicare & Medicaid Services (CMS) has changed its Star Rating system, placing greater weight on measures related to patient experience. While the changes take effect in 2023, based on the timing of the surveys, consumers will be asked to consider their perceptions about their plans beginning in the latter half of 2021.

"If you don't want to let be left behind with 2023 Star Ratings, or if you want to continue to use experience as a way to differentiate and outperform, you need to be taking action today," says Amy Amick, president and CEO of Alpharetta, Georgia-based SPH Analytics, a firm specializing in healthcare analytics and population health. Her company works with a majority of the nation's 216 Medicare Advantage health plans, which hold more than 700 contracts with CMS.

A J.D. Power study released last week found that Medicare Advantage "information and communication is a weakness for member satisfaction, which is driving a general lack of engagement among consumers and increases the likelihood of health plan members switching plans," according to a news release. The study is based on responses of 3,314 members of Medicare Advantage plans across the United States, fielded from January through March 2020.

A different study conducted by SPH Analytics, released on June 9, echoes the need for better communication, specifically related to COVID-19. Of the 2,000 respondents surveyed between May 5 and May 11, 2020, only 37% said that their health plan reached out to them with information regarding the virus, and even fewer said their personal doctor reached out (29%).

While the J.D. Power and SPH Analytics studies looked at communication, the primary changes to the Star Rating system are related to patient experience, access, and complaints, says Amick. Star Ratings not only help consumers decide what plans to select, but also impact the plan's eligibility to receive quality bonus payments. In the five-star system, plans must achieve at least four stars to qualify for those payments.

There are 47 measures that comprise the Star Rating score, which are divided into different categories, explains Esther Turner, principal, product management, for SPH Analytics. Each category is assigned a weight of one to five, The patient experience, access, and complaints category was recently elevated from a weight of one-and-a-half to two. The category will be weighted a four in the 2023 ratings.

While plan administrators may think they have time to make changes impacting these categories, the 2023 date is deceptive, says Amick. While the adjustment goes into effect during 2023, the surveys related to those ratings will be conducted in 2022 and ask consumers to look back six months. Therefore, she says, consumers' perceptions of their Medicare Advantage plans in the latter part of 2021 will be reflected in the 2023 Star Ratings.

"CMS is very clearly saying experience matters," says Amick. It is now "a much more substantial portion of how overall star ratings are done. It's a big, bold statement by CMS about the importance, criticality, and value they're placing on the experience of a member."

Changing member's perceptions about their experience does not happen overnight, says Turner. "It's important for plans, especially for those that struggle with [ratings], to start thinking about how to have quality programs in place to move the needle because their competitors are already thinking about that."

Data analytics can help plan administrators take a closer look at their performance and how they are trending against other organizations, says Amick. Taking a deep dive into this data can ultimately save a company time and money by focusing improvement efforts only where they are needed most, she says.

For example, high-level data might show that members feel that access to care is an issue, she says. Yet a closer look might reveal that "women in the rural population of western Pennsylvania are most dissatisfied with access to care."

Further research could reveal what's driving those perceptions and opportunities for improvement. The solution might include providing more physicians and specialists in that area and conducting an outreach campaign to those members.

"If [the plan] just looked at the high-level data that said that there was a problem with access to care, and they worked really hard to build out more access to physicians across the totality of the state of Pennsylvania, they would have wasted a bunch of time and money because they didn't focus on where the real need was, which was a sub-stratification of the population," Amick says.

To improve perceptions, she says, "I would suggest that plans need to ensure appropriate sophistication, to be very cohort- and needs-specific as they go forward, and drive changes into their operations. When a plan is thoughtful, data-driven, targeted and very prescriptive, they're able to very effectively move the needle and drive improved outcomes and experiences for their members. Organizations that take that mindset clearly are able to not just improve, but disproportionately perform in the market, compared to other organizations."