Will an Emphasis on Patient Experience Align Star Ratings With Better Quality, Savings?

'The challenge is, how do plans maintain and increase Star scores in the clinical measures for higher-risk members while proactively enhancing the customer experience,' poses one executive.

It has been exactly one month since the Centers for Medicare & Medicaid Services (CMS) published its 2022 Star Ratings for Medicare Advantage plans. One year from now, Star Ratings measures for Patient experience will quadruple in value—a shift in priorities that may disrupt plan ratings and benefits parity. And while some external Stars measures data pose challenges, payers' own data and operational focus can help create a robust, integrated Stars strategy that achieves what CMS' program shift is designed to accomplish.

Star Ratings measures, weights, and methodology change annually to reflect CMS priorities and address parity across measures and plans to ensure continuous performance improvement. For the 2022 MA plan year, Stars Ratings include multiple measures across five categories weighted from one to five: Outcomes, Intermediate outcomes, Patient experience, Access, and Process. Plans that earn 4.0 stars or more qualify for quality bonus payments while plans that achieve 5.0 can market year-round.

The soon-to-be quadrupled weighting of the Patient experience category is no small change. It means that customer experience metrics will represent 57% percent of an individual health contract's overall Star Rating. A prior HealthLeaders article featured this payer call to arms from Amy Amick, president and CEO SPH Analytics, a firm specializing in healthcare analytics and population health: "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." Amick's advice came more than a year ago, a time for plans to begin to act given the challenge of improving customer experience.

Can a focus on customer experience move the needle?

McKinsey notes that while "customer experience measures have been a component of Stars ratings for years, health plans have not been as successful in improving their customer experience compared to other industries." Clearly it is time for a change, and for multiple reasons. For more than a decade, analysts have been citing the Star Ratings "Lake Wobegon" effect, named for a fictional town where "all the children are above average." In 2022, approximately 90% of MA enrollees are in plans rated four stars or higher.

McKinsey further notes that the Stars program has generated $15.1 billion in payer incentives. Despite this, the MA program is not achieving one of its primary objectives: to generate savings for the overall Medicare program while delivering higher quality, coordinated care. This is according to MedPAC, the independent agency that advises Congress on the state of the Medicare program. In its March 2021 report, MedPAC notes that "aggregate MA payments … are about 4 percent higher than expected FFS expenditures." They further add: "The current state of quality reporting in MA is such that the Commission can no longer provide an accurate description of the quality of care in MA."

Similar challenges abide in the Medicare Shared Savings Program (MSSP), which established accountable care organizations (ACO). MedPAC reports have "shown modest success in improving quality" and "modest reductions in spending relative to their benchmarks" compared to FFS." This includes the NextGen ACOs that take on greater risk and which have resulted in no reduction in spending when accounting for shared savings distributed. It's important to note that 43% of MSSP quality measures pertain to patient/caregiver experience.

Implications for payers

While the above data raises questions about Stars and customer experience metrics as a direct path to savings and quality, plans certainly can't go wrong in treating their members well. Amick from SPH Analytics notes that Patient experience can be a payer strategy to "differentiate and outperform"—an especially important one given the current parity in not only Star Ratings but another development leveling the playing field: MA plan supplemental benefits. Randy Strite, director of government programs practice with healthcare consulting firm FluidEdge, notes: "This is not your parents' Medicare. This is a second generation in terms of the rating model and benefits offered.

CMS notes that "[t]he Star Rating system helps Medicare consumers compare the quality of Medicare health and drug plans being offered. As part of this effort, patients are empowered to make health care decisions that are best for them." Improved retention is a possible outcome, given that positive experiences should drive customer loyalty. And while MA members already tend to stick with their plans (85% between 2013-2019), Star Ratings that weight customer experience over clinical outcomes could impact this dynamic.

Embedded challenges

The above-referenced dynamic raises one of the most important questions about the new Stars Ratings weighting, also raised by FluidEdge: "How do plans maintain and increase Star scores in the clinical measures for higher risk members while proactively enhancing the customer experience and ensuring sound operational processes are in place?"

Another challenge is how difficult customer experience is to capture, in general and given the nature of some of the data used to measure it. A portion of Star Ratings Customer Experiences derives from CAHPS. Star Ratings include 21 CAHPS measures across six domains.

Cherié Shortridge, vice president of government programs practice at FluidEdge, highlights the challenges of the data arising from these measures: "CAHPS scores are deidentified so health plans can't nail down the results to specific customers or regions, etc. CAHPS questions are also quite vague and subjective, questioning consumers as to needs versus wants and this is where health plans have trouble. They are tapped into the data but feel they don’t have as much control."

A broader challenge on payers' 2023 Start Ratings is the impact of current baseline scores. Shortridge notes that "[p]lans had artificially inflated scores for this year [2021]; they received the better of the scores from this year and last year due to the impact of COVID-19."

What payers can do

These challenges, and the importance of proprietary intelligence, can inform a payer's readiness for strong 2023 Star Ratings. "This is where health plans need to take a fresh look at their own data," Shortridge notes. "Plans don't have to wait for CAHPS to understand what drives member dissatisfaction. Their own complaints, grievances, and appeals are a window into what needs to be fixed from an experience perspective. This data is also included in the plan operations metrics (e.g., appeals decision timeliness and uphold rates, or how often a plan's original decision stays after appeal and external review), as is the availability of translation services," says Shortridge. "Plans have the operations metrics down because of clear numerators and denominators, and the availability of real-time data."

Plans may also miss opportunities to improve experience by not considering all of their customer-facing departments, including care management, disease management, and call center operations. "These are all points of light as to the root causes of poor customer experience." The balance, then, is between what Strite calls "managing to the metric" where that yields value and a comprehensive view in other areas.

"It's important to take a systems-wide view of contributing factors—what are you successful at, what can you tweak," says Shortridge. Her firm's approach for working with payers includes assessments, road mapping, strategy, intervention, implementation and two analytics tools: a Stars decision engine and score forecasting based on what/if analysis.

"Stars is not a single event"

Despite MedPAC's assertion that Star Ratings quality reporting is insufficient, it is the best mechanism currently available and one that requires a sophisticated, strategic response. "Stars is not an action," says Shortridge. "It's not a single event. It’s a way of operating, of taking care of members and managing customer experience. It is a culture, embedded in everything you do. If you're meeting customer needs with quality, positive Star Ratings will follow."