Principal, Product Management
Person-centered care and the voice of the consumer have become increasingly vital measures of quality in the health care delivery system. Most of the rigorous quality programs that exist for various aspects of health care, be it for health plans, hospitals, home health, hospice, and others, each incorporates a variety of quality measures ranging from process measures, clinical outcomes, and patient experience.
CMS doubled-down on the importance of experience measures as part of a longstanding pledge to put patients first and to empower patients to work with their providers to make health care decisions that are best for them. This came in the form of new guidance about the relative weights of measures used in the Medicare Advantage Star Ratings.
These Stars are used to assign quality ratings to private health insurance companies that provide Part C and Part D coverage to Medicare beneficiaries. The ratings are available to consumers when they choose among competing plans during enrollment. They are also used to reward high-performing plans with financial bonuses. These bonuses can amount to significant revenue for health plans and are only awarded to plans achieving at least 4 out of a possible 5 stars.
Experience measures have always been included as a part of the Star Rating program. However, CMS has increased their relative importance to the overall rating by increasing the weight given to these measures. Recently CMS increased them from 1.5 to 2, and then last week (June 1) it was announced that they would increase again, this time from 2 to 4.
To understand the impact of this, consider that most other measures in the program are currently weighted at either 1 (process measures) or 3 (outcomes). The measures that will move to the new weight of 4 include the patient experience of care measures collected through the CAHPS survey, Members Choosing to Leave the Plan, Appeals, Call Center, and Complaints measures.
It is even more critical now for health plans to have in place both a solid plan to understand their member experience and targeted quality improvement initiatives to make sure they stay ahead of the curve. This change takes effect for the 2023 Star Ratings, meaning it will use the CAHPS data collected in the spring of 2022, which asks members to look back six months into their experiences in 2021.
If member experience hasn’t been a priority for your organization, now is the time to start making plans for how you will amass the right data to operationalize improvements.
Most of the comments submitted to CMS from health plans opposed the increased weights for the experience measures for a variety of reasons. CMS spoke specifically to the COVID-19 pandemic in their response to some of the comments, noting that:
“The uncertainty from the pandemic is a critical time for plans to be focused on patient experience. Plans need to enhance patient experience to deal with the challenges of COVID-19 pandemic, to work with beneficiaries in customized ways, and be as supportive as possible.”
CMS continued to reinforce the importance of patient experience as a critical part of a quality framework that ties directly to other aspects of patient care:
“Patient experience is an inherently important dimension of healthcare quality. It is also the case that the preponderance of evidence shows that better patient experience is associated with better patient adherence to recommended treatment, better clinical processes, better hospital patient safety culture, better clinical outcomes, reduced unnecessary healthcare use, and fewer inpatient complications.”
Since most health plans tend to perform well on the CAHPS measures relative to other measures, CMS expects this change to actually result in a cost to the Medicare Trust Fund, offset by other changes noted in the Final Rule.
My “back-of-the-napkin” math using the 2020 Star Ratings shows that, of the 401 contracts with a 2020 Overall Star Rating, less than a quarter might have seen a decrease with the new weighting system in place. However, the CAHPS cut-points are subject to change every year depending on industry performance, so it’s imperative that health plans focus on improvement strategies for the CAHPS measures.
At SPH, we have not seen a significant impact in our preliminary Book of Business from COVID-19 this year. In fact, some measures are scoring higher than last year. If this trend continues, plans need to prepare to increase their measure targets.
We’ll share more highlights from our Medicare CAHPS Book of Business once we finalize data. Since CMS is not collecting data or publishing any updated cut-points this year, we know plans are anxious to understand how their performance compares to others across the industry in these truly extraordinary times. The Final Rule is availablehere: https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-11342.pdf. The discussion of measure weights begins on page 153.