An "October Surprise" in Medicare Advantage Star Ratings
Each year, one of the most anticipated announcements in the Medicare Advantage (MA) industry is the Star Ratings and program technical guidance for the coming year from the Centers for Medicare & Medicaid Services (CMS). This year's includes an "October Surprise:" a little-known methodological change that could force dozens of 4- to 5-Star-rated plans to lose their hard-fought bonuses and rebates.
Roughly 370 MA plans are currently scored under the Star Ratings system, which we all know by now is graded on a curve. Plans above 4 Stars get substantial bonus payments and bid rebates from CMS and above 5 Stars can market and sell their products year-round. In this sense, plans below 4 Stars are circling the toilet bowl as there is only so long they can compete against the better benefits of 4+ Star plans. The Star Ratings for 2017 will likely knock many 4+ Star plans off their pedestals. Here's why: for 2017, for the first time, 188 new plans could be scored under Star Ratings.
- 64 of the 188 are Medicare-Medicaid Plans (MMPs), which CMS announced in June will be moved into their own separate Star Ratings program this fall. This is a bit of bad news for most MA plans, since their inclusion in the MA Star Ratings program would likely have helped fill the lowest end of the curve.
- The 124 that are left still represent enough mathematical volume that their performance will shift the bell curve. Most will likely earn an overall rating of 3 or 3.5 stars, which will cause rating dilution for those at 4+ Stars. If those plans have the same level of performance as the previous year, they will likely dip below 4 Stars. This is a looming disaster for those companies because they've already booked the bonus money and predicated their benefit designs and 2017 campaigns on receiving the rebate.
- Regarding the 6 "dead men walking" plans below 3 Stars for 3+ years and slated for termination: a "hospital improvement" bill, which passed the House and is still in the Senate, includes a provision to delay CMS' authority to terminate MA contracts based on poor Star Ratings for 3 years. It's possible these 6 plans may continue to fill the very lowest end of the Star Ratings bell curve, thus helping other low-performing plans by padding the lowest end of the bell curve.
Many plans are going to get a nasty shock when they dig into CMS' latest news. It's another stark reminder Star Ratings management is a constant campaign, and plans cannot afford to get comfortable when it comes to their quality performance.
Resources
CMS recently notified plans of the first preview period for the 2017 initial Star Ratings data. It is critical for plans to begin the annual re-evaluation of Star Ratings performance now to pinpoint new problem areas, implement tactical actions, and identify improvement opportunities to raise ratings. Read full analysis >>
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Complaints — Make Sure They Are the Gift that Keeps on Giving
Have you ever received a gift you knew had value, but you just weren't sure how to use it to its full potential? Complaints are very much like that. We need to change our view of complaints and consider them to be gifts from our members that need to be opened and cared for as the important pieces of information they are. Complaints are something we all wish would never be needed, but every health plan receives them. Our members have needs, and sometimes those needs don't appear to our members to be met. In those instances, if we are lucky, the health plan receives the complaint. If we are not lucky, our members' neighbors, acquaintances, doctors, or even worse — regulators and congressional representatives' — receive the complaint.
Regan Pennypacker, Gorman Health Group's (GHG's) Senior Vice President of our Compliance Solutions Practice says it best, "Complaints, grievances, expressions of dissatisfaction — these are a part of life in the course of running any government program. The processes are in place to provide an avenue for your membership to speak openly about their dissatisfaction and provide you an opportunity to take that data, analyze for trends, and, if possible, make changes in an effort to improve quality."
Here are four components for making the most of that opportunity:
- Train staff to hear complaints. There is a delicate balance in Customer Service to identify complaints. Some Customer Service staff members are so focused on fixing the immediate issue, they don't recognize the additional complaint concerns. An example of this is a member calling to change his or her primary care physician (PCP) because things are "not working out with this provider." It is easy and beneficial to help the member change to a new PCP, but what is the underlying issue that needs to be explored? If the health plan doesn't know what is going on, there is no way to resolve the matter for this caller or other members. Having staff trained to recognize when a complaint is presented is the first key step to successful complaint management.
- Correct categorization of complaints. This is an often discussed topic as it is a high audit risk and a frequent audit finding. A complaint is identified, but what type of complaint is it? Customer Service is often the first to talk to members about their concerns. Sometimes the call is an inquiry or an educational opportunity or a misunderstanding that can, with the right information, satisfy a member. Other times the call is regarding a complaint that is an appeal, grievance, coverage determination or organization determination, or a combination of several types of complaints. Ensuring knowledgeable staff and clear support tools are in place to correctly categorize those complaints allows members' concerns to be heard and addressed and appropriate due process to occur. If a member calls to complain about wanting but not being able to get a specific medication, that will most likely fall under a coverage determination or appeal if it was previously denied by the plan. Obtaining all the details will allow for a thorough and correct determination. What if it is a provider who was not willing to discuss any other formulary options, even if the member explained the drug makes the member sick? Possibly there is a quality of care grievance that needs to be explored; carefully categorizing a complaint is the next critical step in processing complaints.
- Empowered, knowledgeable staff who can thoroughly investigate the complaint. Regan summarized this well, "Skilled, knowledgeable, empowered grievance and appeal coordinators are key drivers in plan satisfaction. Yes, the complaints will still come in, but what are you doing about them? How are those addressing grievances empowered to turn that interaction into a positive customer experience?" Some of my greatest product loyalty has been developed when I called to complain about an issue, and the company representative listened, investigated, and resolved the issue. It wasn't always resolved in the manner I wanted, but I knew I was heard and that what could be done was done. People processing complaints have to understand the importance of a complaint reported to the plan and be empowered to manage that complaint in the highest customer-focused manner.
- Tracking, trending, and root cause analysis. Often times there is a disconnect between all the information gained from complaints and ways to make that information useable to improve processes and quality. Most plans track their complaints and report them to the Quality Committee. Some plans analyze the information searching for trends that can be managed and processes that can be improved. They look at the root cause of the issue that caused the complaint to see what can be done differently going forward. They evaluate the data to see who else might be impacted and proactively work to remediate the situation. They truly see the value of the gift provided to them to improve their organization.
Complaints are like constructive criticism: hard to hear sometimes, but they can make a big difference going forward. Just as it takes a strong person to adapt to constructive criticism, it takes a change in culture to value complaints as an opportunity to change and improve. Finding the worth in your members' complaints will make your plan a stronger, more customer-focused organization. Does your organization leverage the complaint gifts you receive and make them count? If not, you are losing a key opportunity on a gift you already have and just don't know fully how to use.
At GHG, our consultants have worked in the weeds. We understand the processes and pain points health plan staff face on a daily basis. We are here to help you as you evaluate your program and adapt to an ever-changing environment. I would welcome the opportunity to talk to you about how we can assist your organization as you strive towards more compliant and efficient operations.
Resources
At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
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Meeting CMS Halfway: The 2016 Audit and Enforcement Conference
On June 16, the Centers for Medicare & Medicaid Services (CMS) held their third annual Medicare Advantage & Prescription Drug Audit and Enforcement Conference and Webcast. At the heart of this conference is the CMS Program Audit. Agency experts as well as Sponsor participants presented to an in-person and webcast audience on expectations, process enhancements, upcoming developments, and more.
While the agency has not given everyone the keys to the kingdom, the transparency of process improvements and changes can be likened to someone meeting you halfway. If you expect CMS to meet you where you are, you'll be waiting a long time. Sponsors need to do the rest: digest the free information provided, distribute to all affected parties, and implement. Practice until each step of an audit runs like a well-oiled machine. Sound cliché? It should. The core focus of this audit model has not changed in years. You may argue that you've had staff turnover or have switched delegates for a certain function. None of it matters. The requirements are still the same, and they are in line with many items your organization attested to upon application.
My summary and analysis of the conference can be downloaded here, however, it is no replacement for watching the webcast recordings on your own and making necessary changes to your program.
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Medicare Program Audits — Four Things Operations Should Be Doing Today
Do you think the Centers for Medicare & Medicaid Services (CMS) program audits are stressful? We often make it worse for ourselves than it already is. Imagine being in the audit webinar pulling up a case and having CMS say that case was to be excluded from the universes. Instead of showing your department, processes, and system capabilities, CMS is getting the impression you don't even know your data well enough to pull a correct universe. What can Operations departments do to get ready? Here are four things you can begin doing today to be ready:
- Set up automated universe pulls, both with internal systems and delegates. Automating these processes will allow you to pull them quickly and use them on a regular and ad hoc basis. Additionally, automating the process will help you identify which fields are not being captured properly or at all in your system. This can be the biggest difficulty in pulling universes and not something you want to find out when you receive your CMS audit notice. Start this process today.
- Learn to use the data in the CMS audit universes. CMS uses these formats for a reason. CMS has fine-tuned this process to allow them to most readily identify outliers and potential issues. This will help you as you monitor your own operational departments and identify hidden trends. It will also help you regularly monitor your delegates.
- Set up time to complete mock audits of the potential outliers. Pick 10 sample outliers on a monthly basis to review to determine if there are issues with your processes or universe pulls. It makes sense to do this within each operational area internally. You should know what is happening within your department before anyone else identifies it; this includes members, Compliance, or CMS. You will be surprised what you will learn through this review.
- See it to the end. Think like CMS when you complete your reviews. Put aside your thoughts on system limitations and department politics and how many times you have tried to address an issue. How does what you find impact members? How does this follow guidelines? If you identify issues, complete the process by running a beneficiary impact and root cause analysis. This will let you know scope and give you the information you need to address the issue. This may be supplying the information to allow a prioritization of a fix you haven't been able to get prioritized before.
When we in Operations see CMS audits as something that is managed by Compliance, we do ourselves a disservice and lose out on one of the most valuable tools we should all have in place. Implementing these processes will change the dynamics of your department, promote ownership, and make a live CMS audit easier.
The Gorman Health Group Operational Performance practice consultants have been in your shoes. We have faced the multiple priorities and pressure to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department, we can help.
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At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Click here to learn about GHG's Operational Performance services >>
Gorman Health Group has decades of experience stress-testing hundreds of operational business units and can assist with implementing CAPs post-audit or in proactively addressing operational problems before regulators come knocking. Visit our website to lean more >>
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Health Plans Need to Start Talking About Disparities in Care
On the heels of a recent groundbreaking RAND report on racial disparities in Medicare Advantage (MA), the US Department of Health & Human Services' Office of Civil Rights (OCR) issued a regulation that requires serious attention in health plans participating in MA, Part D, Medicaid, and ObamaCare. It's a game-changer in advancing health equity and reducing disparities.
The new regs, implementing Section 1557 (the nondiscrimination provision) of the Affordable Care Act, prohibit discrimination, marketing practices, or benefit designs that discriminate on the basis of race, color, national origin, sex, age, or disability. This will escalate disparities from simply being a "quality improvement need" to being a huge compliance issue. It goes without saying that an investigation of your plan by the civil rights cops splashed across local news would be devastating. As the Centers for Medicare & Medicaid Services (CMS) has begun more aggressively using their data to identify these disparities, health plans certainly should begin doing the same.
The final rule prohibits sex discrimination in healthcare, including by:
- Individuals cannot be denied healthcare or health coverage based on their sex, including their gender identity and sex stereotyping. These last two items are of particular importance given transgender policy enforcement is relatively new. OCR has prosecuted cases recently where transgender patients were discriminated against in hospital admissions and room assignments, denying mammograms to transgender females, denial of gender reassignment surgery as "cosmetic," and harassment by medical transport drivers.
- Women must be treated equally with men in the healthcare they receive and the insurance they obtain. OCR has prosecuted several cases recently where hospitals assigned male guarantors when a wife obtained services but not the other way around.
- Categorical coverage exclusions or limitations for all healthcare services related to gender transition are discriminatory.
- Individuals must be treated consistent with their gender identity, including in access to facilities.
- Sex-specific health programs or activities are permissible only if the entity can demonstrate an exceedingly persuasive justification.
The regs also include important protections for individuals with disabilities and those with limited English proficiency by:
- Requiring covered entities to take appropriate steps to ensure communications with individuals with disabilities are as effective as communication with others.
- Covered entities must post a notice of individuals' rights, providing information about communication assistance, among other information.
- Covered entities are required to make all programs and activities provided through electronic and information technology accessible to individuals with disabilities, unless doing so would impose undue financial or administrative burdens.
- Covered entities cannot use marketing practices or benefit designs that discriminate on the basis of disability.
- Covered entities must make reasonable changes to policies, practices, and procedures, where necessary, to provide equal access for individuals with disabilities.
- Requiring covered entities to make electronic information and newly constructed or altered facilities accessible to individuals with disabilities and to provide appropriate auxiliary aids and services for individuals with disabilities.
- Requiring covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Covered entities are also encouraged to develop language access plans.
Resources
CMS recently announced the release of the 2017 Medicare Marketing Guidelines for Medicare Advantage Organizations and Part D Sponsors, which include added language, clarifications, and new requirements. Join Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Carrie Barker-Settles, Director of Sales and Marketing Services, on Tuesday, June 28, from 1-2 pm ET, to discuss what provisions in the final guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes. Register now >>
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Why are the Dual Eligible Demos Such a Hot Mess?
There's no avoiding the steady stream of bad news facing the Centers for Medicare & Medicaid Services (CMS) financial alignment demonstrations for dually eligible beneficiaries. Enrollment is declining, beneficiaries are opting out at epic rates, and leading states like California are slowing their efforts despite crushing budget realities. Dozens of health plans have invested millions to participate in what's become a hot mess. Where do we go from here?
An early priority of the Affordable Care Act was to give states great flexibility in transitioning dual eligibles into health plans. Back in October 2013, over 60 participating health plans began enrolling dual eligibles through three-way capitated contracts with 13 states (VA, MA, IL, OH, CA, TX, SC, MI, NY, MN, CO, WA, RI) and CMS, representing a $40 billion annual revenue opportunity. After a strong start through the first half of 2015, the pilot programs for the most vulnerable patients in the U.S. health system started hemorrhaging. Net enrollment has declined for the last 4 months. Overall, only 30% of eligible beneficiaries are enrolled — way below expectations. The demos have been plagued by beneficiary opt-outs over 70% in some states, scared off by anti-managed care providers and advocacy groups. In some states, over one-third of eligibles "simply can't be found."
Some of these issues, like difficulty in locating dual eligibles given their widespread transiency, come with the territory and call for a much more aggressive community-based outreach and education campaign by state officials prior to the launch of these demonstrations. High rates of opt-outs show that outreach also must include providers and advocacy groups, especially those for the disabled, who "defined the terms of the debate" with beneficiaries and talked them out of participating before launch. One advocate noted, "Seniors have many doctors because they have multiple chronic conditions. Even the thought of losing a physician … is enough not to sign up."
Last year, CMS conducted an independent analysis of the state demos, which found that states didn't realize how much it would cost to implement, especially in IT infrastructure. They found huge issues with enrollment, despite a phased approach, and found health plans had a hard time keeping up with basic reconciliation, coverage and payment transactions. With this came the issue of trying to find beneficiaries to complete their initial health assessments and to educate them on the benefits of the demo in the first 90 days of enrollment. Large-scale demos, such as in Los Angeles County, were plagued with problems, whereas less ambitious launches went more smoothly. This argues for more 1915(c) home and community-based services waivers on a smaller scale and less monster 1115 waiver projects.
But the fundamental issue remains — the enrollment process —and here is where policy must change. Focus groups show that more than 40% of opt-outs were unaware they had done so — this in a state where 89% of enrollees are satisfied with the program once they are in it. This argues that voluntary enrollment is counterproductive to the goal of enrolling dual eligibles in coordinated care. Massive community-level outreach to beneficiaries, advocates, and providers must be required and paid for, followed by passive and/or facilitated enrollment processes that automatically enroll beneficiaries into plans unless they affirmatively choose otherwise. Anything less only results in pilot projects that fail to thrive.
Resources:
Join us on Thursday, May 26, from 1-2 pm ET, for an in-depth webinar analysis of the key changes finalized in the new Medicaid regulation, how these changes will affect states and managed care plans, as well as how to adapt. Register now >>
More than 200 health plan clients and an additional broad range of other industry participants each year trust Gorman Health Group's team of professionals to deliver expert counsel and tools to help them meet their goals. We pride ourselves on having both day-to-day alignment with the latest CMS guidance and the long-term strategic vision to keep it all in perspective. Contact us today >>
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Latest Sherlock Benchmarks Confirm Medicare Advantage is a Miserable Beast to Manage
The geniuses at Sherlock Company, whose benchmarks on health plan administrative standards are considered the gold standard, have released their 2016 findings and the numbers paint a clear picture: Medicare Advantage (MA) is a miserable beast of a product. It's complicated and labor- and capital-intensive, requiring tremendous patience for executives and investors alike.
First: Sherlock's benchmarks confirm that MA requires nearly double the staff per 10,000 members as do commercial group products, and nearly triple that of Medicaid managed care. Much of this staffing is driven by unique requirements in the "Account and Membership Administration Cluster" (Enrollment / Membership / Billing, Claim and Encounter Capture and Adjudication, Customer Services, and Information Systems.)
Second, successful MA management requires big investments and, above all, patience. Sherlock found investments in Medical Management, Star Ratings and Sales/Marketing in Medicare takes at least a year, and often much longer, to show results.
Third, Sherlock demonstrates seniors are high utilizers of customer services relative to all other insured populations, and low costs are not optimal costs. Plans that spend little on service typically suffer worse member retention, membership growth, and customer satisfaction. MA members have longer service handle times, higher appeal rates, much higher rates of claims inquiries, and are less likely to utilize automated call systems.
The upshot? Once you master MA, all other lines of insurance business are a walk in the park in comparison. If this was an easy business, we'd be out of business.
Resources:
More than 200 health plan clients and an additional broad range of other industry participants each year trust Gorman Health Group's team of professionals to deliver expert counsel and tools to help them meet their goals. We pride ourselves on having both day-to-day alignment with the latest CMS guidance and the long-term strategic vision to keep it all in perspective. Contact us today >>
Under the provisions of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), physicians and other practitioners will face a Hobson's choice: live with a more aggressive risk-based adjustment to payments or join forces with an alternative delivery model, like an Accountable Care Organization (ACO), that is taking risk. Read the full article >>
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An Important Component of MACRA: Quality Measures Development Plan
The Centers for Medicare & Medicaid Services (CMS) recently released a proposed regulation that will implement the payment incentives through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). An important component of these new incentives is the Quality Measure Development Plan (MDP), which CMS finalized and posted this week. The purpose of the MDP is to create a strategic framework for the future of quality measure development to support MIPS and advanced APMs.
Under MIPS, clinicians will see a payment adjustment beginning in 2019 based on their performance score across four performance categories: quality, resource use, clinical practice improvement activities, and advancing the use of information technology. Under advanced APMs, payments must be tied to quality measures comparable to those quality measures used under MIPS. These quality measures will be developed by CMS by November 1, 2016, as required by MACRA, and CMS will utilize this new MDP to guide the development and implementation of these new measures. CMS currently has an ongoing solicitation to stakeholders to assist in finalizing the initial set of measures.
CMS will also incorporate the seven core measure sets recently released by the Core Quality Measures Collaborative, a partnership between America's Health Insurance Plans (AHIP), CMS, and other industry groups. The plan notes its focus on coordinating with federal agencies and other stakeholders in order to lessen the duplication of efforts within the industry and promote person-centered healthcare.
The MDP notes current known measurement and performance gaps and solutions to close these gaps through new quality measures. For the first measure set, the MDP posted the initial priorities for measure development in six quality domains: clinical care, safety, care coordination, patient and caregiver experience, population health and prevention, and affordable care. CMS will update the MDP as they identify new gaps in measurement and performance in order to develop additional quality measures annually.
In reviewing the recent MACRA legislation for potential changes, and putting together comments to CMS, organizations should also carefully review the new Quality MDP in order to ensure their comments are incorporated into the release of the first set of measures by November 1, 2016.
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CMS recently released the proposed rule that sets forth the replacement for the Sustainable Growth Rate (SGR) formula and creates the new payment system based on value rather than volume. Daniel Weinrieb, GHG's Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, along with our team of experts will provide a detailed analysis as well as industry recommendations. Stay tuned!
50/50 Just Won't Cut It — You Have to Commit 100%. The Top 5 Components for Successful, Compliant, Committed Operations
If you weren't able to make it to the Gorman Health Group 2016 Forum this year, you missed a dynamic time. More than just relevant topics, it included engaged participants who added a wealth of depth to our discussions. The topic garnering a lot of audience participation was "Can Operational Efficiencies and Compliance Co-Exist?" The struggle to align the two is real and takes constant, diligent effort, but the success it can create is priceless.
I told a story about a recent vacation involving a shark swimming in the surf. At one point it started swimming towards a father and son. Those of us on the pier were yelling to warn the man to leave the water, but he couldn't hear us. It wasn't until the people on the beach carried the message to the man that they got out of the water. Oftentimes we rely on the Compliance Department to carry the weight of maintaining compliance, but like the people on the pier, that message only goes so far. To be effective and make a real change, the message has to be embraced by everyone in order to make a real difference.
Here are the five critical points to ensure operations entwines compliance in its core:
- Don't Ignore the Human Factor — Our employees are the most critical factors in our department's productivity and compliance. Make sure our employees are well trained on not only the technical components of the job but on the critical compliance requirements as well. Employee engagement, like member engagement, is critical to success. Our employees want to do a good job, but sometimes they don't fully understand all that success entails.
- Know the "Why" behind an Action — What vision have you imparted to your staff? Are they just keying in applications, or are they setting up and welcoming members into your plan? Do your employees think compliance is an obstacle to be circumvented or a process to be embraced? Making that transition occurs by showing the "why" behind the action. How does what they do, both individually and as a department, impact our members? What is the logic behind why the Centers for Medicare & Medicaid Services (CMS) requires that activity? What they do is important, and making sure they understand all the reasons why makes your vision their vision.
- Have the Right Tools — Manual work-arounds and systems that have been duct taped to manage Medicare Advantage and Part D cause most of us the greatest headaches and compliance failures. There is no magic wand to resolve this—it takes diligence, documentation, and prioritization on a continual basis to raise up the next critical system needing to be resolved. Have your list of things needing to be fixed, the additional costs associated with the status quo, and the member impact ready and on the enhancement list.
- Provide Measurable Results of Success and Failure — Have a highly-visible way to measure individual and team success and failure. Successes should be celebrated. Share the successes and bring the feedback to your team. Failures should be evaluated—it isn't about the "who did it" but about the "why it happened." Everyone should be focused on mitigation. One of the items the audience discussed is ensuring you eliminate a culture of fear so staff is engaged in reporting non-compliance so it can be addressed. When non-compliance is identified, embrace it and thank those who raised the issue. Let them know how this positively impacted the department, company, and members.
- Manage Up — Sometimes we in management are the biggest barriers to compliant operations. We look at the production numbers and don't focus on the compliance measurements. We only give senior management what they ask for—it is our job to make sure the critical metrics and measurements go up to senior management. They often don't know the right questions to ask or measurements to review, and it is our job to bring this forward—it protects the company and our members.
We all have a part to play to ensure efficient, compliant operations are in place for our members. It takes 100% commitment to make sure the vision is carried forward. At Gorman Health Group, we know how important it is to link compliance and productivity. We are available to join with you to ensure that vision is firmly established in your organization. Please contact me directly at jbillman@ghgadvisors.com.
Resources
At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
The ABCs of Member Satisfaction
Member satisfaction. Customer centricity. Member retention. Consumer experience. Regardless of the term used, the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey measures continue to be the common denominator by which the Centers for Medicare & Medicaid Services (CMS) measures a health plan's success, creating a positive member experience. CAHPS® survey responses now represent 16% of a Medicare Advantage (MA) plan's overall Star Rating, and an additional 33% is comprised of member-reported health outcomes and administrative measurements of member access and experience. With approximately 50% of the overall Star Rating now driven by some element of the member's experience, many health plan leaders now better appreciate the value of consistently providing members with excellent service and a positive experience.
I recently had the pleasure of listening to a group of members from a variety of MA plans share their health plan experiences with industry leaders. Though health plan discussions regarding member experience are often abstract and very general in nature, listening to the experiences of actual members is always a refreshing way to remind ourselves not only what a privilege it is to service the healthcare needs of Medicare beneficiaries but also how emotionally our "routine hiccups" impact members. Not surprisingly, this group of MA members shared stories that illustrate we've still got room for improvement in our quest to create a 5-star customer experience. The experiences of these members spotlight some of the ABCs for a successful member experience:
Access — When members discover providers with closed panels, struggle to make timely appointments with physicians, experience arduous referral or service authorization requirements, or are unable (even if only temporarily) to obtain medications at the retail pharmacy, we reduce the likelihood of the member reporting positive experiences with our plan on their CAHPS® survey. Because many problems have multiple and/or multi-layered root causes, use of a technique such as the "5 Whys" can efficiently and effectively support root cause analysis of issues so impactful improvements can be rapidly deployed.
Better Communication — Many plans struggle to effectively communicate with members and often compensate by over-communicating to members, particularly via low-cost channels such as mail and IVR. By carefully crafting outreach strategies, letters, mailings, and scripts and using each member's preferred communication channel(s), plans can improve the effectiveness of their communications and demonstrate customer-centricity to members.
Coordination and Clinical Context — During the early years of Star Ratings, many plans deployed measure-specific tactics and interventions which were often conducted by disparate teams. In many cases, such tactics were implemented without anyone "connecting the dots" to ensure such strategies passed the "common sense" test from the member's perspective or that such tactics were appropriate within the clinical context of the member's overall health status. By strategically planning and developing outreach scripts and workflows, leveraging Health Risk Assessment (HRA) and claims data, and developing effective business rules through which to identify member interventions, plans can identify the right intervention for the right member at the right time.
Determination and Decision-making — Organizations with a sustained, strong customer experience are intensely focused on consistently making decisions that deliver value to their customers and meet customer expectations. This requires persistent determination, particularly as problems arise which necessitate process improvements or additional resources to resolve. Transforming a health plan into a consumer-focused organization with strong CAHPS® measure performance often requires a new or refreshed consumer focus within each operational area (from benefit design to care management to customer service to sales/marketing) supported by an effective customer experience leader and customer experience governance structure.
The member experience will continue to be a necessary core competency as the industry evolves over the next few years. Gorman Health Group (GHG) understands this can be challenging, both logistically and politically.
Whether your plan needs help establishing an effective member experience or member communication strategy, cataloging and evaluating existing member communications, or identifying opportunities to streamline and strengthen the return on investment from existing materials, tactics, or interventions, we can help. For additional questions and inquiries about how GHG can support your organization's member experience efforts, please contact me directly at msmith@ghgadvisors.com.
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Today you need to identify opportunities to increase your score for next year, implement an enterprise-level strategy, and carefully monitor your progress over the next plan year. We can help you every step of the way with our full portfolio of GHG practices, products and services.Visit our website to learn more >>
Our distinguished team of experts collaborated to provide our interpretation of this announcement and the key features that will have the greatest impact on the industry, emphasizing core business functions in Risk Adjustment, Provider Network, Quality, Compliance, Pharmacy, and Data Integrity. Download our full Summary & Analysis of the Final Rate Announcement & Final Call Letter >>
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