CMS Doubles Down on Member Experience

At Gorman Health Group, we have the privilege of collaborating with organizations across the full spectrum comprising our members’ experience – from health plans and providers to vendors and pharmacy benefit managers (PBMs) – and though almost every person I talk to in every type of organization strives to create excellent member experiences, many struggle to successfully do so. The Centers for Medicare & Medicaid Services (CMS) recent pledge to put patients first in all of their programs has changed the calculus of “the member experience” in Medicare Advantage (MA). We’ve heard these words for years, but this time it’s real.

Not a believer yet? Take a look at just a few of the noteworthy recent changes:

  • The recently released Final Rule increases the weight of Patient Access and Experience Star Ratings measures from 1.5x to 2x beginning with the 2019 measurement year. To illustrate the magnitude of this change, if it had been effective for the 2018 Star Ratings, these measures would have comprised 49% of the overall Star Rating (compared to their current 37% of the overall rating). And don’t forget – CMS may not be done with these measures yet! CMS has signaled their intent to further increase the weight of these measures in the future to better value the voice of patients in evaluating the quality of care provided.
  • The new Open Enrollment Period (OEP) that begins in January 2019 allows MA members to elect another health plan between January 1 and March 31 if they discover things aren’t as they were promised when they enrolled. A member of our Operations team reminds us, “Now more than ever, a health plan should make sure its processes are in excellent working order. ” And according to our Chief Consulting Officer, “The OEP is a game-changer in many ways.” This gives members an opportunity to really try out your plan, kick the tires, so to speak, and see if it delivers on what was sold to them. From your onboarding strategy to coordinated collaborations between operational, clinical, pharmacy, and other departments, delivering on the value proposition your sales and marketing teams took to the market has never been more important.
  • The new flexibility afforded by CMS’ expanded definition of health-related supplemental benefits for 2019, combined with CMS’ reinterpretation of the MA uniformity requirements and further expansions of supplemental benefits for chronically ill members in 2020, provides a utopic environment for MA plans to offer robust benefits tailored to their members’ needs.

In my experience, conversations about “the member experience” are often abstract, frequently very general in nature and rarely tightly aligned with the specific elements CMS will ultimately hold the plan accountable for (such as Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and Star Ratings performance). However, these changes from CMS give us a new lens through which we can make our decisions (both strategic and tactical) more focused. For example, in every daily decision, it is valuable to ask:

  • How could this decision impact the affordability of physician services and medications?
  • How could this decision impact our members’ access to inpatient or outpatient care? To the medications their physicians prescribe?
  • How could this decision support improved health outcomes among our members?
  • How could this decision impact our administrative Star Ratings measures?

Although most MA plans refer to their enrollees as “members,” these changes will force us to realign our thinking so we think of our enrollees as “customers” from an internal perspective, and as “patients” as they use the benefits and services they purchase from us when they enroll. This is a great time to re-evaluate the important factors driving strong access and experiences.

Whether you need help establishing an effective member experience or member communication strategy, cataloging and evaluating existing member communications, or identifying opportunities to streamline and strengthen your member engagement tactics or interventions, we can help.

Speak with our experts today.


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