Reprinted with AIS Health permission from the May 20, 2021, issue of RADAR on Medicare Advantage 

Medicare Advantage plans are at a critical juncture in their quest for quality bonus payments, as this month marks the end of a three-month data collection cycle that will have a meaningful impact on the 2023 star ratings, when member experience measures take on a larger weight in star ratings calculations. While it’s too late to make a difference in how members responded to the recent Consumer Assessment of Healthcare Providers and Systems (CAHPS) that reflects the patient experience in late 2020 and early 2021, MA organizations should be focused on innovations that can prevent and resolve issues members face throughout the year to foster more positive feedback for future surveys, advises one longtime stars expert. 

As numerous measures based on CAHPS and CMS administrative data move from a weighting value of 2 to 4 starting with measurement year 2021, the increased value of those measures will make up 32% of the overall 2023 star rating on a weighted basis. “Just two years ago it was only worth half that much, so we literally doubled the relative value of CAHPS and the measured member experience through these surveys in the math path toward 4 stars,” says Melissa Smith, who is executive vice president of consulting and professional services at HealthMine. “We’ve always known member experience was important and we’ve always agreed we need to focus effort and attention in that area but attaching such a heavy contribution to the overall star ratings to the surveys is the forcing function that most plans are seeing as the impetus for new actions.” 

For our occasional series of interviews that examine pertinent issues through the words of the industry’s leading executives, Smith discussed some of those actions with AIS Health, a division of MMIT. 

Editor’s Note: The following interview has been edited for length and clarity. 

AIS Health: Many of the questions that are asked in CAHPS-based measures relate to how quickly patients are able to access care or prescription drugs. For example, one data source for the Getting Appointments & Care Quickly measure is the question, “In the last 6 months, how often did you get an appointment for a check-up or routine care as soon as you needed?” Isn’t it hard to ask questions like that during a pandemic, when things are far from normal? 

Melissa Smith: Yes, it has been hard to ask those questions during the pandemic, and this has really been the genesis of CMS giving plans so much flexibility during 2020 and the early part of 2021 to compensate for that. So, it’s literally because of that question that we’ve seen the absolute explosion of telehealth, and it’s not just stars [that led to that], it’s also the risk adjustable nature of telehealth that CMS gave plans during the pandemic that drove that map to telehealth exploding.  

CMS did and does expect their health plan partners in Medicare Advantage to get creative to solve those real barriers, and we’ve seen a lot of great creativity in the marketplace, particularly now that the vaccinations have started to become so much more commonplace [and] readily available and our seniors and frail disabled were at the front of the line for vaccination. 

 AIS Health: How do you see those innovations impacting CAHPS responses that were collected from March to May? 

Smith: The explosion of telehealth definitely has mitigated the impact that COVID was having on provider offices. What we’re hearing is that even toward the end of last year, which was squarely in the six months measured by the survey, we really understood how the virus worked, we understood that masks worked, and our doctors’ offices had pretty full patient rooms toward [the second half of 2020]. Telehealth got us through the summer months but by the end of the year, virtually all of our provider community claims [that] they were back to routine course of business with masks. 

 So, when you think about it from a CAHPS standpoint, the question in my mind is, how much will the member attribute COVID in their response? Will the member say, I couldn’t get appointments, tests, treatment, drugs because they felt like they couldn’t leave their home or will they just see that as that was all of us, that was just COVID? 

 AIS Health: How are you seeing member engagement tactics change to account for the increased weight of CAHPS measures?  

Smith: What we’re seeing plans do, first and foremost—and a lot more than they’ve been doing in the last three to five years—is more robust member engagement. We’re seeing plans begin to modernize their efforts in ways that truly reach their entire population—everyone from unhappy members to sort of not terribly unhappy members that are a little complacent to unengaged members to very engaged members—you name it. 

 So, I’ve been [working] with my clients on a couple things, and first is to recognize the reality that you’re probably going to have to blend in digital engagement to human engagement in order to accomplish that at scale. And the use of digital engagement for things like CAHPS interventions then allows us to really treat CAHPS measure monitoring improvement the same mathematized way we treat HEDIS and PDE [prescription drug event] measures as gaps in care. 

 AIS Health: Can you provide an example of a digital engagement strategy in that area? 

Smith: My favorite example for digital engagement is to deploy a mock CAHPS survey to your members that they can just fill out on their phone. We then use their data to identify the members with poor responses at which point we call that a gap in care, the same way we would have categorized a missing mammogram or a missing eye exam as a gap in care, and then we deploy a phone call or a personal home visit or appointment scheduling assistant to resolve that gap in care they reported to us during their digital mock CAHPS survey. 

 In the digital world you can do that entire exercise in under a 24-hour cycle, because once the member submits the digital survey response data, if you’ve got the right administrative platform, you can surface the gap up to the right doctor or the right internal staff member that very same day. It’s just real time, whereas in the past you had to go through an exercise of finding a vendor to do the surveys by mail or by phone and then package it all up and send it back to somebody at the plan. And it might take 30 or 60 days to make it useful data, and in most cases, plans didn’t make their make survey data actionable at all. 

 There are plenty of examples of experiences inside of retail pharmacies and health plans that are known to cause member abrasion in CAHPS surveys—things like rejected claims, denials, missed services—and again, in a digital world those are the sorts of things that when you see the digital-data driven events you can then deploy your digital member engagement tool to tell the member you’ve seen the difficult event and ask if they are getting the care and services they need. And you offer them the chance to tell you that they’ve either gotten it somewhere else and everything is okay, or they need some more assistance. 

 It happens all the time in Part D, that a doctor will write a prescription for a medication that is not covered on the formulary and the members show up at the retail pharmacy only to find that their coverage doesn’t pay for that medication and they leave empty handed. So [with] digital engagement, you can see how we just immediately find those rejected claims and deploy the nudge to the member to make sure they were able to get that medicine, apologize for the disruption, let them know we care and then ask if they need help getting an alternative script from their doctor. 

 AIS Health: There are only two Part D measures based on CAHPS: Rating of Drug Plan and Getting Needed Prescription Drugs. Is it possible that members’ experiences with drug coverage can spill over into the other experience measures on the Part C side? 

Smith: Absolutely. Negative experiences inside the retail pharmacy do not just impact the Part D CAHPS measures; they have a very persistent and longstanding taint on the Part C CAHPS measure responses as well. And when you look at the underlying data in the CAHPS survey, there is a very longstanding statistical correlation between poor access to medications on that Part D Getting Needed Drugs measure and all of the Part C measures. It’s not just a hypothesis, it’s very much manifested in substantially every plan’s data sets from their official CAHPS vendor. It’s a really big deal, particularly as plans change formularies, as plans deal with skyrocketing drug prices, there’s just a lot of impact there. The other interesting thing that a lot of plans forget is that our members have a very long memory of even very isolated negative experiences. 

 AIS Health: Is there anything else I’ve failed to ask that you wanted to address? 

Smith: The only thing I might emphasize is the concept that in order to truly perform differently on CAHPS, you truly have to operate differently than you did in the past, and that’s hard. It is not just tweaking last year’s tactics to be a little more member friendly. In large part, it is doing dramatically different types of work and using dramatically different strategies to change performance than most folks realize. 

 By Lauren Flynn Kelly