Improving Medicare Advantage Consumers’ Experience to Maximize CAHPS Performance

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When it comes to Consumer Assessment of Healthcare Providers and Systems (CAHPS), even Medicare Advantage health plans that currently perform well may face an uphill climb under intensified expectations. For contract year 2021, CMS quadruple-weighted the surveys, which ask members about their experience with their health plan, providers and drug plans.

Dual-Eligible Special Needs Plans (D-SNPs) — whose members are eligible for both Medicare and Medicaid enrollees — are particularly at risk of falling below the four-star threshold, because the healthcare system’s complexities are historically difficult for this vulnerable population to navigate. With approximately $450 per member in annual quality bonus payments (QBP) at stake, strong CAHPS performance is critical to the bottom line.

Surprisingly, despite the multi-billion-dollar Star Ratings QBP pool, Medicare Advantage (MA) plans continue to rely almost exclusively on spreadsheet lists and other antiquated case management tools for measure improvement campaigns. This approach to advancing quality is disconnected and eliminates the ability to engage with consumers holistically. What’s more, consumer interactions cannot be reported and analyzed in a meaningful way to inform next steps and interventions.

CAHPS Is a Defining Factor for 2023 Medicare Advantage Star Ratings

With 32 percent of the overall Medicare Advantage Star Rating dependent on CAHPS measures for consumer experience beginning in the 2021 contract year, MA plans need to modernize their approach to maximize outreach efforts and drive better value-based care.

This increase in CAHPS weightings puts healthcare on the same level as other industries that have been prioritizing the consumer experience for some time, such as banking, retail and software. Further, CMS has signaled it is considering including Net Promoter Scores (NPS) in future MA Star Ratings. A standard measure of customer loyalty, NPS captures how likely a customer is to recommend an organization to others. To do well on this measure, plans will need more loyal enthusiasts (“promoters”) than unsatisfied customers (“detractors”). Good consumer experience will increasingly be more competitive.


What Are Consumers Saying About Their Medicare Advantage Experiences?

On the surface, MA plans have maintained stable performance on CAHPS scores overall by averaging 3.34 stars and 3.33 stars in contract years 2019 and 2018. However, not all plans will weather the new measurement weighting adjustments equally. For example, analysis of the measures by plan type reveals D-SNPs perform quite differently as compared to other MA plans. D-SNPs performed 5.8 percent worse for CAHPS measures than non-D-SNP plans in contract year 2018 when the weighting was 1.5x. The weighting shifting to 4x in 2021 will have a tremendous impact on D-SNPs. CMS already adjusts quality and adherence measures for D-SNPs but does not provide a curve for CAHPS.

In addition to looking at CAHPS data, there are other important sources to help you better understand consumer sentiment. The results of the 2020 U.S. Medicare Advantage Study from J.D. Power provide some deeper insights.

The study aggregated responses from 3,314 Medicare Advantage plan members in the first quarter of 2020. The study revealed that even though there is a motivated consumer base, plans continued to miss the mark on communication.

Consider these key findings:

  • Effective communication is necessary to build satisfaction and trust. When plans communicate well and hit essential key performance indicators (KPIs), consumer satisfaction increases 209 points on a 1,000-point scale. Those KPIs relate to communication around understanding out-of-pocket costs, health education and reminders about preventative services.
  • According to the study, only 15 percent of MA plans are hitting all three KPIs. The pandemic has only exacerbated this communication breakdown. Respondents conveyed that they were over three times more likely to receive helpful communications from their bank than their health plan.
  • Digital channels are great for communication with consumers, even for seniors, 40 percent of whom use digital means to gather information on their health coverage. Further, MA consumers use the medium far more than those who are privately insured.

The increased emphasis on CAHPS measures is a call for plans to directly address these communication struggles, which are a major factor in the consumer experience. Many consumers, especially D-SNPs and those with low health literacy, struggle to access care without proactive, easy-to-understand communication from their plan.

The Star Ratings shift presents an opportunity for MA plans to strengthen communication via strategic consumer outreach and connections that will drive better value-based outcomes. Leveraging technology to strategically engage with consumers and respond to their needs will position the plans for the future as CMS continues to increase its expectations for consumer experience.

Create Targeted Outreach Programs

Using a customer relationship management (CRM) approach to engage members will enable MA plans to improve consumer experience throughout the year by maximizing each interaction with individual members. Beyond general touchpoints, work on creating or optimizing targeted outreach programs. Looking at the KPIs from the J.D. Power survey, your outreach approach should include helping consumers understand out-of-pocket costs, educating them about health and sending reminders about preventative services.

Ensure consumers have access to out-of-pocket cost information they can understand. You can do this by creating guides that are concise and easy to read, keeping in mind that only 12 percent of American adults are considered to have proficient health literacy. Place a digital version of this information on your website and mail consumers a hard copy. For health education, develop an extensive resource center on your website and help consumers locate specific resources when you’re on a call with them. Preventive service reminders are ideal for email and SMS campaigns.

To target the most at-risk consumers, such as the D-SNP member population, you can leverage analytics tools and build out plans based on data you can monitor, such as medical and pharmacy claims. Segment consumers who aren’t adherent to their medications, haven’t had their annual screenings or need assistance managing chronic conditions.

Once you have these lists, use an integrated, multiple-channel approach to communicate. The type of notification and the consumer’s preference should inform your channel choice.

Focus on Medication Adherence as a Pillar of CAHPS

Medication adherence is critical for consumers and quality measure improvement for MA plans. Medication-related measures account for more than half of the overall Star Rating. What’s more, nonadherence costs the health system considerably, accounting for more than $500 billion of annual unnecessary healthcare spend, and leads to adverse outcomes for consumers. It has a significant impact on consumer health — and, therefore, consumer satisfaction — and is also a sign of disengagement.

Instead of letting nonadherent consumers fall through the cracks, leverage claims data to identify them at the first sign of nonadherence. Look for a technology platform that can analyze big data and apply risk stratification, comparative benchmarking and prioritization. Once you know which consumers are nonadherent, use the data-driven insights to conduct intelligent outreach and engage consumers over time with a focus on overcoming social determinants of health (SDOH) barriers.

Out-of-Pocket Costs

Even with insurance, some medications still may not be affordable for all consumers. Give your clinical outreach team the tools to access and relay information about community resources that could provide financial assistance as well as possible alternatives, such as generics or manufacturer rebates, if cost is a barrier. Additionally, you can advise consumers as to which pharmacies offer the best prices for specific prescriptions.

Mobility Constraints

Not everyone has easy access to a pharmacy. Without reliable transportation or pharmacies nearby, consumers may not have a way to pick up their medications. Share helpful advice regarding plan transportation benefits or available medication delivery options from pharmacies that specialize in helping consumers with complex medication protocols and offer specialty services such as compliance packaging.

Lack of Education on Medication Benefits

Consumers may not be fully aware of the difference regular medication adherence can make for their health—or they may not understand how to take all of their medications as prescribed. This is particularly common for consumers with multiple chronic conditions who have complex medication regimens. In this scenario, your clinical outreach team should use motivational interviewing tactics to engage the consumer directly on overcoming SDOH obstacles and low health literacy over time. If necessary, clinicians can also bring the consumer’s care team into the conversation.

Streamline and Manage the Consumer Experience

Prioritizing the consumer experience to optimize CAHPS scores includes many factors, stakeholders and processes. Streamlining and managing the consumer experience isn’t feasible without technology. If you want to improve the experience, you need to systematize your clinical workflows. If you’re tracking things with spreadsheets, it’s time to upgrade so you can scale your initiatives and engage with your consumers in an intelligent, holistic way.

Resolve™ for Medicare Advantage Star Ratings, an Adhere Platform™ solution, can help. It’s the first comprehensive, consumer-centric platform that addresses consumer experience and boosts Medicare Advantage Star Ratings.

The CRM model allows your clinical team to continually engage with consumers over time to overcome barriers to medication adherence and care. With this one powerful tool, you’ll be able to address 80.5 percent (80.5%) of MA Star Ratings weightings regarding medication adherence, quality improvement and consumer experience.

Resolve is available as a SaaS (software as a solution) or a tech-enabled clinical service that can continuously ingest critical data points, including CAHPS, pharmacy/medical claims, Healthcare Effectiveness Data and Information Set (HEDIS), eligibility and hospital discharge data.

Resolve analyzes real-time data in a streamlined, intuitive clinical workflow so you can proactively discover which consumers are at risk of medication nonadherence. It focuses on quality measure improvement while maximizing the consumer experience to support better CAHPS and Health Outcomes Survey (HOS) results. Resolve integrates with community resources and health plan benefits to provide every opportunity to drive quality improvement and consumer experience. Your team will be able to target consumers for outreach to ensure they have the information and care they need when they need it, and their better outcomes will have an impact on your ratings.

Master the Medicare Advantage Consumer Experience with Resolve

Resolve is leading the way toward a data-driven, personalized consumer experience. With robust features and functionality, it can make a significant difference in your workflows and your ability to monitor your CAHPS performance and consumer perception.