The weight of the CAHPS® survey has steadily increased over the years from 8% in 2014 to 32% of the overall Star Rating in 2021. Scoring is complex and there’s no one size fits all strategy. Two health plans the same size can do the same thing and get different results. The reason for this is attributed to the unique nature of every member experience in different member populations.  

There are a number of variables that contribute to positive CAHPS performance. Although CAHPS performance can’t be pinned to one effort, the health plans that are most successful have a wholistic strategy that involves multiple departments and synergies between their member communications and outreach. Every single thing that’s printed on paper, published on websites, sent via email, or communicated verbally—matters. Carefully crafting and optimizing a targeted member journey is essential to successful CAHPS. It’s often forgotten that health plans are surveyed not just on their own interactions with members, but also their agents and provider networks. Education and onboarding partners to deliver a member experience is just as important as training customer service representatives. All member touch points are a reflection of the health plan.

In order to improve the member journey, plans must evaluate their available data from multiple perspectives. For example, it’s no longer sufficient to evaluate appeals and grievances through the narrow lens of whether it was an appropriate denial or not. Today, plans need to also analyze complaint data from a quality vantage point and determine it its more expensive to have an abrasive member experience.  

Host: Hello to everyone joining us today. Welcome to Episode 5, Improve CAHPS® With Existing Data & New Perspectives. We’re here today with Amy Weiser, Managing Director of CAHPS Performance. Amy has over 20 years of experience in health plans, facility and practice management. She’s held leadership roles for Star and HEDIS initiatives, operations, member and provider engagement, medical management for care management and utilization departments, and is responsible for starting a new quality and patient experience department for a large physician network. It’s great to have you on the show today, Amy.  

Amy: Thanks, I’ve been looking forward to it.

Host: So Amy, what are you seeing that’s new in CAHPS right now?

Amy: Obviously, COVID put a wrench in everything. There are a lot of disaster policy components that are getting lumped into Stars. As of now, CMS has not given official guidance on how it’s going to go in 2022. It’ll be interesting to see if they allow plans to choose the better of two scores, this year or last year. As of now, we don’t know.

From a business perspective, COVID provided an opportunity for health plans to interact with their members through extra phone calls, and a lot of plans sent care packages. You know, like branded masks, hand sanitizers, and that sort of thing. It doesn’t sound like a big deal, but the plans that did this seemed to do well on CAHPS scores.  

The other thing that’s new in CAHPS is the weight of the survey on Star Ratings. In 2020, CMS increased the importance of CAHPS, and then they increased it again in 2021 to 32% of the overall Star Rating. To give you some perspective, back in 2014, it was weighted at 8 percent. So, it’s a big shift, especially since CAHPS is so elusive.  

Host: CAHPS scoring is complex. You know, two health plans the same size can do the same thing and get different results. Why do you think this is?

Amy: Yes, this is the case. And it’s because every member experience is unique, and there’s no one way to approach every single member population. There are variables that every health plan needs to factor into their strategic approach for CAHPS. CAHPS is like an octopus with tentacles, it goes into everything. There are so many nuances to it, and you have to take the time to look at all the different pieces. And have multiple departments looking at it.

Even your agents can affect CAHPS in the way benefits are communicated. The worst thing is… a new member comes on board and they thought their PCP was in the network, but guess what, they weren’t. They don’t leave the plan; they stay, but when it comes time for the CAHPS survey and they’re asked about the plan, they say it’s horrible cause I had to switch PCPs. And now, they only see them twice yearly because they don’t have that history or connection. And we all know that will affect more than just your CAHPS.

It’s important to educate your agents, ensure they understand your plan’s benefits, and provide them with the support materials they need to communicate your benefits. Set review meetings with the sales teams. What are they seeing in AEP?  

Educate your providers on your benefits so their interaction with members is positive. Are you making it easy for providers to get a hold of the plan? Is the process for appealing a denial easy? How they can request a non-covered benefit for a member? Is there cohesion across partners in the kinds of materials that go out? Providers, case management, customer service—are they all operating from a well-thought-out, integrated communication plan? Look at the overall member communication process. Who’s communicating with the member and when. The whole communication process needs to be managed with an interdisciplinary approach so there are no duplicate efforts. You want to make sure the timelines across departments are aligned. You don’t want multiple departments sending the same type of communication. Every single thing that’s printed on paper and on websites or emailed matters in member experience. This is why it’s important to keep the marketing team connected with the Stars team to ensure messages are aligned across all departments, partners, and accounts for all phases of the member journey.

Host: That targeted member journey is so important. And you’re seeing that in every facet of life these days—so it makes sense that healthcare is no different. Another area of member experience that’s really influential is your providers' impact on your members. It’s another hot topic in CAHPS right now. You know, how do health plans establish true partnerships with providers so that providers are engaging and communicating with members?  

Amy: It’s true. A lot of people forget that health plans are surveyed not just on their own interactions with members, but also their provider network’s interactions. All member touch points are a reflection of the health plan.  

Host: That’s a great point. What are some ways health plans are establishing these provider partnerships and getting providers on board as co-creators of the member experience?  

Amy: First, it’s important to approach providers from a ‘what’s in it for you' standpoint. Instead of making the partnership about your Star Ratings, help your providers to create stronger relationships with their patients. When patients feel more comfortable with their providers and they feel like they’re being heard—these patients are more likely to listen to their providers and are more likely to follow through with their plan of care. Focus on supporting and educating your providers from a clinical perspective and help them strengthen the clinician-patient relationship. A strong clinician-patient relationship is going to provide the member with a positive perception of their healthcare, and that reflects the health plan, too.  

There are also incentive models that enhance the provider-plan partnership. These incentives provide additional revenue streams for providers, usually a per member per month structure. Incentives help cover the additional costs incurred—because it does cost more to execute these member engagement activities and provide staff training on how do it. It costs more to do follow-up calls with members. It’s all about the human element of things. Beyond checking the box that the lab has been done, it’s calling and talking to the member about it.

Another way to reinforce the provider-plan relationship is to offer co-branded patient education materials. The member sees this collaboration and it gives them a sense that the provider and the plan are a true team—working on behalf of the member.  

Some plans offer chronic, high-risk case management assistance to practices, it’s called Patient-Centered Medical Home. Other plans are offering technology to support the providers with closing gaps within their already existing EMR. There’s care management technology that provides streamlined workflows and makes the provider’s day easier, and all parties can see what’s going on. At the end of the day, all of these things are ways to shore up the provider-plan partnership by saying, “We care about you and we are here to help.” That goodwill extends all the way to the patient/member level of care. It all ties in together: CAHPS and HEDIS gap closure, case management, the call center, benefit communications, and marketing. Anything, everything, and anyone who could potentially interact with a member has the ability to affect the whole member-patient experience.  

Plans have to make it clear and easy for providers to request a review or appeal process. You don’t want the providers complaining about the health plan to members, “I wanted to order XYZ for you, but your health plan denied it, they are so hard to work with. We’ve sent so many messages.” And here the patient is sitting in front of their provider hearing this negative review about their health plan. Members look up to the provider. So they think, “If my provider can’t trust my health plan, how can I trust it?" So, making sure processes are smooth for the provider matters a lot. The more health plans can integrate technology into their provider’s workflows by closing gaps and providing care management technology to get everyone talking the same language, the better it is for everyone. But it’s up to the health plan to lead that process.

Host: I love the idea of creating a healthcare ecosystem, so to speak, where everyone is aligned and working together. The system got so disconnected for a while, and it's really exciting to see the movement towards a holistic model. I think a lot of this is driven by technology and data. Now, in respect to data and analytics, where do you see CAHPS opportunities for health plans in the coming years?

Amy: One area of opportunity that a lot of health plans overlook is taking a step back and looking at data that’s right in front of them with a new perspective. For example, look at the plan’s complaints to Medicare. I mean, look at it from a quality perspective. Don’t look at it from the angle of whether it was an appropriate denial or not. Look at it with curiosity. Is there an underlying issue that’s coming through for the CTM, and then cross-reference it with what’s getting appealed, and what’s getting denied? If something was denied and it’s appealed, and then the appeal isn’t upheld and it’s overturned and that care is still given. Wait a minute. Are we seeing the same trend? Are we denying the same things that are ending up in appeals, and we’re still paying for it? Is this a repeated issue that’s causing abrasion for our members? Plans have to evaluate their CTMs, appeals, and grievances from a member experience perspective. A lot of times, it's more expensive to have an abrasive member experience.

What’s not getting resolved? Is there an issue with the customer service team not understanding a benefit? Do the customer service reps need more training? Dig into what’s going on. One way to do this is through call calibration. This means pulling the recordings from calls and listening to the actual call. If there is an issue with a call, then circle back. This can be very insightful. One time, I was on a call with this great customer service rep, a high performer, but we discovered that—oh my goodness—for some reason, the provider was listed as out of network… but it wasn’t true. The problem was that the listing was incorrect.  

The take-home is that there’s a lot of data plans already have at their fingertips, and they don’t even know it.

And then, predictive analytics is a new area of opportunity for plans to get proactive glimpses inside of their member population. Plans can take their CAHPS results from the previous year and use the low-scoring areas to point towards areas of focus. Then, you can take that area and dig into the data with questions that get to the root of what happened. You know, you might ask, what type of members are more likely to report dissatisfaction? It’s this type of segmentation that can provide insights as you drill down and quantify patterns of behavior. This is a really exciting area of opportunity—you know, taking the data, making sense of it, and making actionable changes that improve the quality of care.  

Host: And that’s what it’s all about, quality of care. At the end of the day, it’s important to remember that. Amy, thank you so much for joining today. I know our listeners had some big takeaways from our conversation. If you’re listening, don’t forget to rate the show and share the episode with your colleagues. We’ll catch you next time.