By Matt Phillion
The fourth quarter of 2021 is here. Changes are coming to Consumer Assessment of Healthcare Providers and Systems (CAHPS) star ratings for 2022, and they’ve set plans and systems on a course to try to improve. But what does this shift mean for providers, systems, and insurers?
“CMS made the announcement a while back that it was going to change weighting from 2x on CAHPS measures to 4x—and what happened was that counted for, in the next star ratings, 32% on patient experience,” explains Jason Rose, CEO of AdhereHealth.
Patient experience is defined by CAHPS surveys—regardless of size, each Medicare Advantage plan will have 800 members surveyed about their experience with the plan, the providers, and the prescription drug program. All eight survey measures that count toward the patient experience rating have quadrupled in weight.
The timing is important to note here as well: CMS typically administers CAHPS surveys from March through May and submits results in June. That means the CAHPS ratings, as part of the results we’ll see in October of this year, have already happened. Most survey questions are about the patient experience in the previous six months, so the results stretch back to the preceding year. Essentially, the 2022 star ratings, announced in October 2021, encompass 2020 plan performance.
But why the mad scramble, if organizations knew about the timing? “What happened was, 22 of the 40 cut points for the eight measures went up, so it caught a lot of plans flat-footed on what they were ready for when their numbers were surveyed,” Rose says.
How this happened might not be immediately obvious, but makes sense: Many of the plans, Rose notes, did the proactive work and made sure they heavily emphasized patient experience from the latter part of last year into the March survey time frame. “And because this is a competitive review, that meant a lot of plans just got crushed in terms of how they performed with CAHPS,” says Rose.
CMS doesn’t completely disclose how it arrives at the cut points, but the agency looks at all Medicare Advantage plans across the country and evaluates how peers are doing on established measures. “If 22 CAHPS cut points went up, that means a lot of plans put a lot of emphasis on patient experience,” says Rose. “Therefore, it got harder to achieve higher ratings. They should be striving to improve, because all the plans are focusing on this right now. Some plans might have been well prepared, but [it’s important to] recognize CAHPS patient experience measure improvement is going to get harder and harder every year.”
The jump in weight and the change in cut points caught even the most prepared plans off guard. “Including plans that did well on CAHPS patient experience, I have yet to come across a single managed care organization that knew CMS was going to increase 22 of the cut points for CAHPS,” says Rose.
How plans need to adapt
To adapt to the ever-changing star ratings, AdhereHealth advises thinking of the patient holistically. “Plans shouldn’t focus on a set of five or six quality measures that happen to be attributed to a patient,” says Rose. “These individuals are human beings who may have problems achieving higher quality results, and that includes multiple measures.”
Rose notes that CAHPS identifies those patients who are not doing well—whether they can’t get the appointments they need (e.g., diabetic patients), struggle with proper care coordination, can’t afford the drugs they are prescribed or don’t understand how their prescriptions work, or even struggle with customer service. “All of those perspectives are encompassed for a holistic patient,” says Rose.
Unfortunately, most health plans still look at patients from a siloed rather than a holistic perspective, he explains. Plans might have several internal teams dealing with different, disconnected quality measures: one team on HEDIS, another on medication adherence, a third on member experience, and so on. “But they’re not looking at the patient as one person stretching across all of those measure components,” he says. “That’s one person who could touch a dozen or more measures.”
The providers or plans may not have the customer relationship tools to adopt a holistic approach, or may not know how to use the tools they do have. “Because analytics are separate, outreach is typically not coordinated either,” says Rose. Any outreach the patient receives is likely in separate pieces: one from the provider, one from the pharmacy, or even one from marketing. “Plans and providers may be coming at the same patient in an uncoordinated way, which is abrasive,” Rose says.
Next, plans need to be more action oriented. “It’s not enough to just call the patient and do mock surveys,” says Rose. “That doesn’t really give you anything other than a proxy of what you think you might score—it doesn’t fix anything. What we believe is you need dedicated programs. Who are the most at-risk patients; those most likely to be surveyed and also likely to score poorly on those CAHPS surveys? Who are they? The people not getting the services they need!”
These are the patients who are not able to get to their doctor, are on multiple medications possibly from multiple pharmacies, may have lousy adherence, and face multiple social determinants of health. “All of those things come out in CAHPS surveys,” says Rose.
AdhereHealth pushes a focus on identifying these patients from an analytical perspective. “Reach out and ask patients how their experience was,” says Rose. Ask them, “It looks like you haven’t seen your doctor in eight months—can we help you set up an appointment?”
This assistance goes beyond just setting up visits. Patients may need food assistance, help understanding their medications, and more. “To solve those SDOH issues, it’s more than acknowledging they exist—it’s fixing the actual issue,” says Rose.
Solving these issues one at a time will make a difference.
“Just the fact that you’re attempting to solve these issues for them—the members will remember those things, and when they get surveyed, they’ll respond accordingly. Yes, someone called me and helped me access benefits I didn’t know I had available to me,” says Rose. “But the outreach has to be action oriented.”
Consumerism in healthcare
The concept of consumerism exists in every industry, and healthcare is no different, Rose notes.
“How do I engage with the patients who are most at risk?” he says. “The first thing you need to do is make sure they’re a part of the process, having a plan for who is ultimately responsible to engage with them in a way that they make their health a priority—which ultimately improves quality of care and reduces cost of care.”
And how does CMS get plans to want to engage with patients in this way? By weighting star ratings accordingly.
“It’s a public/private partnership,” says Rose. “To me, the star ratings are the best example of value-based care by leaps and bounds—every year, the way they’re structured makes it more challenging, removing measures that are easy to achieve and adding new ones that move the dial.”
The focus on engagement and patient experience isn’t going anywhere soon. “It’ll be a while before we see them reducing it from 32%,” says Rose.
Star ratings enable plans to have a better product than their peers, he notes. Health plans are looking for ways to be more profitable, and the ratings motivate them to increase quality and improve the end results.
“If you’re not at four stars, the plan is not competitive,” says Rose. The star ratings have a demonstrable effect on membership numbers, which are ultimately the measure of a plan’s financial success. “For every star rating, there’s an increase of 8%–12% membership. These ratings are a really important component of plan growth.”
As patient experience becomes front and center, plans are more and more motivated to get its fundamental concepts right.
As October arrives and January’s further changes to weighting appear on the horizon, plans are already looking ahead to the next scramble to keep up with changes in scoring—and to stay ahead of the competition.
“I suspect a year from now we’ll be talking about the 2022 changes already announced by CMS, and plans may be ill prepared for the results,” says Rose. “But there’s an opportunity to be proactive.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.