Star Ratings Take Aim at Member Experience in ‘Huge’ Shift

Reprinted with AIS Health permission from the July 2, 2020, issue of RADAR on Medicare Advantage.

CMS, building on its multi-year theme of emphasizing member experience within Medicare Advantage (MA), is increasing the weight of member experience measures beginning with the 2021 star ratings. By the 2023 star ratings, member experience will represent nearly one-third of plans’ overall star ratings, potentially leading to a significant reshuffling of MA plans achieving bonuses, analysts say.

Given the COVID-19 pandemic and these changes, which take place within the pandemic’s confines, plans may need to scramble to adjust, the analysts say.

“CMS is really emphasizing the patient experience and the patient’s perception of their care, both from the plan and with the plan’s provider network,” says Melissa Smith, senior vice president, stars and strategy for Gorman Health Group. “Of course, they’ve always had that as an element of stars — they’ve always had the patient experience listed in there. But this is the first time that we’re really disproportionately going to see [patient experience] weigh on stars.” CMS will increase weighting of experience measures derived from the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey and retire other measures that CMS believes plans have maxed out, such as the adult body mass index assessment.

That means 32% of the star rating will represent member perceptions, Smith tells AIS Health. “So, it’s huge.”

“This has been coming for a while, and plans — particularly the more thoughtful and progressive plans that are out there — really have started to make this a way of doing business,” adds Matt Siegel, specialist leader, Deloitte LLP. As a result, success in the stars system will begin to depend heavily on how an organization approaches star ratings, Siegel tells AIS Health.

CMS said in late May that it would move ahead with what it terms “Star Ratings enhancements” by increasing measure weights for patient experience/complaints and access measures. For 2021, CMS has increased the relative weighting of patient experience measures (obtained through CAHPS), complaints and access from 1.5 to 2, which means they’re weighted about 4% more. Then, beginning with the 2023 star ratings, CMS will increase the weight of those measures from 2 to 4, “reflecting CMS’s commitment to put patients first and to empower patients to work with their doctors to make health care decisions that are best for them.” The change takes effect even though CMS received multiple requests to delay any changes to the quality rating system until after the COVID-19 pandemic subsides.

The agency also said it would move forward with plans to use the Tukey method for removing outliers before calculating star measure cut points, delaying the impact of their removal until the 2022 measurement year to be reflected in 2024 ratings.

Because of the pandemic, MA plans won’t be required to submit 2020 Healthcare Effectiveness Data and Information Set (HEDIS) or 2020 CAHPS survey data to include in 2021 star rating calculations. An analysis by Deloitte found that roughly 50% to 55% of 2021 star ratings will be calculated using 2018 performance data, which was used for the 2020 plan year, while between 45% and 50% of 2021 ratings will be based on 2019 data.

The increased emphasis on member experience in the stars program comes when the star ratings system has been stable for about the last four or five years, Smith says. However, that’s now shifting, she adds, with a “sheer volume” of revisions to the system that hasn’t been seen since the program was in its demonstration phase, back in the early part of the last decade.

Experience Measures Are Tricky

CMS now will emphasize measures in which many plans historically have struggled, she says. In fact, the two areas in which plans struggle most are CAHPS and the Health Outcomes Survey, and beginning in 2021, those two surveys will be worth a combined 41% of the overall rating, Smith says. “So plans that are really comfortable with mammograms and colonoscopies and eye exams — that’s just not going to be where the math needs them to be looking in order to keep their star rating strong.”

Analysts had been anticipating some of these changes, since CMS had been signaling them for years, Smith says. However, she says she had expected the agency to triple-weight the CAHPS measure, not quadruple-weight it, particularly since “so many plans lobbied against it and provided feedback against it. I think they really hoped against all hope that CMS would not do this, but CMS has been signaling very, very, very transparently for a couple of years that their focus is on the beneficiary, their experience, their access, their perspective, their opinions. So this has been inevitable.”

To prepare for these changes, MA plans will need to “take a very hard look at what they’re selling, how they’re packaging it and communicating it to the consumer, and then how effectively they’re acting upon what they promised the consumer they’re going to get,” Smith says.

“It’s fair to say many plans are not quite ready to do this well, but there’s no time like the present to start, because we believe the program is going to continue to evolve very dramatically,” Smith says. “For plans that are feeling uncomfortable with these CAHPS and these measure weight changes, there’s no time like the present to just dip their toe into the uncomfortable space, because we’re going to be uncomfortable in stars for the foreseeable future. There’s clearly no end to this.”

To succeed in the new member experience-weighted star system, MA plans will need to consider star ratings and member experience in almost every aspect of their organizations, and incentivize, manage and measure staff performance, Siegel says. “The ones that I have experienced that really can embed this and ingrain this in their operations across the board” can succeed, while those that consider stars to be a quality issue that’s lumped in with HEDIS measurement may fail, he says.

“It’s really infusing everything you do — for member outreach, for care management, for stars, providers’ bedside manners, and other things like that — into your day-to-day operation,” adds Akhil Rao, manager, Deloitte Consulting.

There are numerous data sources for plans to measure member experience, Siegel says. Examples include how often are they touching members in various forms of care management and wellness outreach, sending people reminders and reaching out through marketing. Plans also can consider member experience in inbound calls, and whether those members ultimately filed appeals or grievances, he says.

“Historically, a lot of those things were either not interrogated, or you couldn’t connect the dots across those different systems to really be able to understand more holistically what was happening,” Siegel says. “I think there’s still a long way to go, but plans are getting better and better about finding those different data sources and connecting those together to create more of that longitudinal picture of touch points that would very clearly and quickly start to reveal trends.”

MAOs May See ‘Seismic Shift’

It won’t be easy for plans to adjust their strategies to optimize performance under these new changes, particularly in the midst of the pandemic, but Smith points out that CMS didn’t intend for this to be simple to do. “CMS is making it hard because they’re learning off of what we do, and achieving the triple aim is intended to be hard work.”

In addition, the measures introduce some clear unpredictability and the potential for what Smith terms as “suppressed star ratings”; in fact, CMS has put plans on notice that these changes could cause fewer plans to earn four stars, Smith says.

Rao says he expects “a seismic shift in how plans will be impacted.” Some plans are doing well in the CAHPS survey, and many of those also are 5-star plans. Those could continue to perform well once CAHPS results make up a far larger percentage of their overall stars rating, he says. However, “some of the local, regional plans have not been doing that well when it comes to consumer experience,” he adds.

by Jane Anderson 

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