Improving Patient Experience To Boost Payer CMS Star Ratings

How CAHPS scores influence more than just CMS star ratings

Many people are familiar with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores that the Centers for Medicare and Medicaid Services (CMS) uses to publish star ratings for hospitals, nursing home facilities, home health, and outpatient surgery centers. But that is not the only way CMS uses CAHPS surveys. 

CMS also uses CAHPS scores to calculate a star rating for Medicare Advantage (MA) plans. This system allows consumers to compare health plans on a range of metrics for quality, performance, network benefits, costs, and patient experience. 

Beginning in 2021, patient experience scores quadrupled weight in the overall Medicare star rating calculations for payers. Payers have a great opportunity to focus on patient satisfaction and improve their CMS star ratings in 2022 and beyond. 

Why CMS star ratings matter for payers

Healthcare was a little slower than some other industries to adopt star ratings as a comparison tool, but today, they are critically important for Medicare consumers who want to evaluate insurance plan choices. CMS star ratings also:

• Provide a standardized tool for CMS to measure the quality of all Medicare Advantage plans and prescription drug plans
• Give plans the ability to differentiate and attract new participants
• Lead to higher per-member-per-month (PMPM) rates from Medicare; higher performance yields higher PMPM, thereby directly affecting revenue

How do CMS star ratings work?

Payer CMS star ratings include scores for Medicare Advantage (Parts A and B) and prescription (Part D) benefits. The ratings are on a scale of 1 to 5. They objectively assess plan value and performance to help consumers find the plans that offer the best value. Achieving a higher star rating indicates better quality, lower plan costs, or both and can help payers attract new plan participants. A higher star rating also makes plans eligible for higher quality bonus payment (QBP) reimbursements, which totaled $11.6 billion in 2021.

Increasing CMS star ratings by improving patient experience and CAHPS scores: challenges and opportunities 

Each year, CMS reviews CAHPS scores and star ratings data and adjusts plan performance metrics according to how plans performed in the prior year. The benefit of this approach is that plans cannot simply maintain their current performance level from year to year—they must continuously improve. 

Changes implemented in 2021 present an opportunity for MA plans to boost star ratings in 2022. Last year, CMS announced that patient experience scores will be quadruple weighted, accounting for 32% of total plan scores. Payers who focus on patient experience scores—while maintaining or improving quality and performance metrics—can see a positive shift in their total Medicare star rating. 

Five strategies for improving CAHPS scores through better patient experience  

To achieve higher star ratings, payers must understand which CAHPS measures to target for maximum impact. These strategies can help payers engage plan participants, improve patient relations, and target important quality metrics. 

Create effective payer-provider partnerships 

There are several strategies payers can use to improve patient satisfaction and increase CMS star ratings. However, when it comes to the patient experience, the providers do most of the day-to-day work to move the needle on Healthcare Effectiveness Data and Information Set (HEDIS) measures. HEDIS metrics are identified and updated by the National Committee for Quality Assurance (NCQA) and provide the most effective standardized metrics for comparing health plan performance. 

One of the most important metrics for achieving HEDIS success is partnering with providers who are committed to closing care gaps to improve patient satisfaction and care quality. Today, value-based care (VBC) contracts often stipulate what quality scores providers must achieve. New VBC opportunities allow payers to structure financial incentives that further motivate providers and payers to innovate and continue improving patient experience. That’s a win for everyone, including providers, payers, and patients. 

Standardize the onboarding process for new plan participants

Onboarding is a crucial time for payers to help patients understand their benefits and how they can maximize the available plan resources to maintain or improve their health. Standardizing the onboarding process ensures that patients are fully informed about everything from networks and providers to prescription benefits. Simple steps like these can significantly improve patient satisfaction scores, resulting in higher CMS star ratings.

Provide targeted care for high-risk patients

People with chronic and mental health conditions account for 90% of the $3.8 trillion spent on healthcare in the U.S. each year. Plan administrators should assess their membership data to spot key trends and opportunities to create new programs or improve care for patients managing chronic health conditions. For example, targeted outreach can improve patients’ medication adherence by educating them about aspects of their plan like mail-order prescriptions and automatic refills. 

Proactive outreach also helps patients, especially those with chronic conditions, schedule preventive care and annual checkups. This step can minimize or eliminate visits to urgent care or the emergency department, which drive up total cost of care for patients. Providing this targeted outreach limits high-cost touch points, making it easier to achieve value-based care cost-savings goals.

Educate participants about preventive care benefits

Preventive care and screenings are covered 100% under MA plans and can help providers and payers close gaps in care. Patients who understand and take advantage of health screenings are more likely to detect diseases early, when they are easier (and potentially less expensive) to treat. Regular checkups also help patients build a relationship with a primary care doctor, contributing to care continuity and better overall health.

Use multiple channels to engage plan participants  

MA plans can assist members in multiple ways by ensuring they have the information they need to make good care decisions. Patients who are engaged in their healthcare feel empowered and more in control of their health situation. Digital health technologies including telehealth, remote monitoring, wellness apps and more also help bridge the gap between patients and their health information.

This involvement leads to higher patient satisfaction (and ultimately higher CMS star ratings) and improves providers’ ability to coordinate care. 

Make sure to:

• Update your website regularly and ensure information is easy to find online.
• Maintain a blog and social media channels to share health information.
• Send email and direct mail promotional and educational materials.
• Contact patients by phone or text message with important health information, plan updates, and more.

Payers that focus on improving CMS star ratings and improving patient experience can lead to higher enrollment, increased revenue to enhance benefits, and a bigger market share for their MA plans. 

Learn more about our patient experience solutions.