2021 was the first year that CMS shifted away from clinical metrics and skewed the weight towards member experience. Health plans will need to address matters such as how well members understand their benefits, the ease of the experience surrounding the use of benefits, and resolution of issues with paying for services—to name a few examples. Member experience is the summation of the entire scope of interactions for a member with their health plan and providers. We're talking with Erica Krieger about what plans can do in 2022 to boost Star Ratings.

Host: Hi, welcome to Episode 1, The Future of Stars. We’re here today with Erica Krieger, Vice President of Quality for Advantasure. Erica has more than 20 years of experience—spanning strategic informatics, management of Star program reporting, HEDIS® operations, forecasting models for HEDIS improvement initiatives, and scoring methodologies. Erica, we’re thrilled to have you on the show today. Welcome.  

Erica: Thank you, I’m glad to be here.

Host: Today, we’re talking about The Future of Stars.

As we know, CMS Star Ratings are an essential aspect of operating a successful Medicare Advantage plan. The end goal is to provide consumers with information on the quality of the health plan and to incentivize health plans to improve the quality of care provided to its members. Now, the actual scoring of the Star Ratings is less straightforward than its intended purpose, and it seems even less so in 2021 with all of the new changes CMS has implemented this year. Can you tell me about some of the most notable changes for 2021?

Erica: Yes, it’s true. This is the first year that CMS will be shifting away from clinical metrics and skewing the weight toward member experience. Things like how well members understand their benefits, the ease of the experience in using their benefits, whether or not they experience surprises when using their benefits, or issues with their providers in getting services paid. All of those little components shape up the whole experience for the member. And each member has a unique perspective on what shapes their experience. What may be a concern for one member may not be a concern for others. I think this is where it’s one of the biggest challenges. It’s so broad in making sure that we’re breaking down any and all barriers for a member across the scope of their interaction with the health plan and their providers.

Host: As I understand it, this focus on the member experience, which is both broad and qualitative, is going to present a lot of challenges and uncertainty for health plans to benchmark their performance against industry standards.  

Erica: There is a lot of unpredictability this year in how they’re rating plans and calculating scores. For example, the Patient Experience score generated from the CAHPS® survey can be tricky for larger plans because the sample size of the survey is so small. It may not not be an accurate reflection of the overall member population. Large plans really need to make sure all members are satisfied to score well.  In addition to the member experience, COVID is still impacting health plans and their Star ratings.  The nation is still in a Public Health Emergency, which creates some unique challenges for CMS.   Last year, given the PHE, CMS had to release additional policies in order to calculate Star ratings for the 2020 measure year or the 2022 Rating.    We’re expecting CMS must do the same this year but it’s unclear if the guidance will be the same as last year or not.

Host: Oh, that does sound challenging. What are some tactics that plans are implementing to facilitate better CAHPS scores and member satisfaction initiatives?  

Erica: There are so many different components. I think some tactics can range from simple things like member incentives to help them build out loyalty with the plan, member education to make sure members understand their benefits, from the more foundational things like making sure the underlying technology is in place to support business functions. For example, if a member calls into customer service, making sure the agent has all of the pertinent information to provide the member with a complete answer.

Plans that are excelling with this are using personalization. What this means is really understanding their member population and different needs. One person may be struggling with how to get a service paid. They saw their provider, the service has been rejected and they don’t know how to move forward. This is a very different need from a member that needs help finding a provider. So, really identifying the sub-populations and the unique challenges they face to set up processes to help resolve these challenges.  

Host: A lot of what you just talked about sounds like there’s a large communications component to a successful member experience—explaining member benefits and delivering member education. What are the most successful outreach methods for communicating with members?

Erica: There isn’t one communication method that works for the broad population. This is going back to understanding the sub-populations and segmenting them so you can address their needs and going a step further, you can communicate with them in the manner that they will respond best to. There may be a population that is 80+ that enjoys postal mail—they want to see it and hold it. But, the younger aspect of the Medicare population has been shown to be very comfortable and even prefer navigating online; they read articles, click ads, set aside time each day to read their email and use online portals.  

Success really hinges on having a strategy in place to deliver the right information to the right member. So all members fully understand their benefits, what’s covered, what’s not covered, what they’re out of pocket may be, so they’re not surprised.  

The biggest component of member dissatisfaction is when they’re surprised by their benefit. They go to the pharmacy, and they’ve been paying $10 for a drug for two years, and now, all of a sudden, it’s $50. Those surprises hurt member satisfaction and loyalty to their health plan. It’s essential to ensure members understand the different factors that may change and limit surprises for them when using their health care benefits.  

Host: How can health plans help members to better understand their benefits to limit these surprises?  

Erica: A member could be on medication therapy, and it’s $10 a month, and then it is changed on the formulary, and the next time the member fills, it’s $50, which was a complete surprise to them.  It’s these nuances that need to be communicated at the time of the question so that the member understands where potential costs can arise and be prepared for that. So, really, there’s a huge component of preparing call centers for these types of calls that will influence Star Ratings. It’s really all about finding key sources of dissatisfaction and challenges—and increasing the knowledge and communication to members to proactively resolve problems.

Host: Given the uncertainty and broad performance measures, what advice do you have for health plans?

Erica: Maintain that spirit of continual improvement across the organization. So even though there is uncertainty, CMS rewards heavily for improvement year over year. Keeping that pace and pushing for continual improvement can really help make sure you’re setting pace against the industry, even in times of uncertainty.  

Host: Let’s talk about addressing clinical gaps—that’s a huge part of achieving Star success. Can you tell us how technology is becoming critical for addressing and closing gaps in care?  

Erica: With paper-based systems, closing gaps in care can be a long, drawn-out process—back and forth between reviewers, coders, and providers. Emerging technologies that integrate with EMR systems can make this process near real-time. So, in a lot of instances, providers are able to close gaps at the point of care. It goes back to the importance of data interconnectivity. Connecting the provider community for health management and facilitating a true collaboration between health plans and providers on behalf of the member. There’s a shift in concept about what is expected from health plans. It’s no longer just providing members with benefits. Rather, it’s moving toward making sure those members are using their benefits. The HOS survey is the component of Stars, where members self-report their health status. This survey is yet another example that highlights the importance of strong care management programs to help members navigate the system so they get the care they need, like timely health screenings or additional benefits like Silver Sneakers.  

Host: What kind of predictive capacity do health plans have to navigate the changes in Stars?

Erica: Predictive model informs how each measure is doing, are we on track for each target and how do we factor in the industry scoring component. Drive differentiation between plans. Changing the targets they set for plans were intended to make success more difficult, broadening the range of performance.

Host: I was reading a 2020 article from CMS, and it indicated that the length of time in the Medicare Advantage program played a significant role in achieving higher performance for Stars. Did this change or remain true?  

https://www.cms.gov/files/document/2021starratingsfactsheet-10-08-2020.pdf

Erica: This will continue to remain a key theme for 2021 and beyond. As we talked about, continual improvement is really critical, and plans that succeed in Stars have a history of what works and what hasn’t worked for their population. Additionally, longevity allows a plan to build up the history of their membership and their unique needs, both at the general population level and at the individual member level.  

Host: What advice do you have for new Medicare Advantage plans just starting out? Is it worth it as a new plan, and how can they jump into the game and achieve a competitive Star Rating?

Erica: It’s definitely worth it. Medicare Advantage plans are becoming the most popular choice of plans in the Medicare space and the demand is increasing as baby boomers are aging in. The important thing to remember as a new plan starting out is that you don’t have to do everything yourself—and to be competitive, I don’t recommend you try. Partner with the experts out there to manage your Stars program so you can focus on other aspects of growing the business.  

Host: That’s a great point to remember. Erica, it was really great to have you as our first guest.  

Erica: Thanks, it was fun.

Host: Thanks to everyone joining us and our sponsor, Advantasure. Follow Advantasure over on LinkedIn, like the episode, share it, and let's continue the conversation on LinkedIn.