MA Plans’ Must-Fix: the Member Experience

Now more than ever, it’s clear to us health plans and their stakeholders will thrive or die based on the member experience they provide. The member experience, especially with drug benefits, now represents more than half of a health plan’s Star Rating in Medicare Advantage (MA), with millions in bonuses and bid rebates hanging in the balance.  It also drives member retention and thereby acquisition expense (now averaging $1,200 per/member, or more than an average month’s premium), so how members are treated now determines both health plan revenues and costs.

Overall, the member experience in a Medicare plan is defined by an enrollee’s ability to get timely appointments, care, and information, how well providers communicate, and whether member-facing health plan and provider staff are helpful, courteous, and respectful.  It’s driven by the company culture, its commitment to communication, and the empowerment of staff to solve problems. And despite two-thirds of plans saying the member experience is their top investment priority, we are losing ground.

In a few short years, the Star Ratings system has evolved from a crappy consumer information tool to a multi-billion dollar pay-for-performance (P4P) initiative investing in improved processes and outcomes of care in MA. In 2016, the scoring methodology for Star Ratings ensures the member experience measures, especially in Part D, count for more than half of a plan’s rating. It also narrows the margin for error, so only a 10% deviation in performance on the critical Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is the difference between a 2-Star Rating and a 4-Star Rating.

On an enrollment-weighted basis, MA averages a 4.03 rating, with 49% of contracts (179) and 71% of members in plans over 4 Stars. But on CAHPS®, the program dropped from 3.45 Stars in 2015 to 3.4 Stars this year. That’s a big problem threatening to drag the program back below the all-important 4th Star and, taken in context of other recent data, gets downright scary.

Last week our friends at Deft Research released their latest Seniors Shopping survey on the 2016 open enrollment period.  They found that for the first time in recent memory, far more seniors are leaving Medicare Advantage for Medigap than vice-versa.

On virtually every measure, they found declining loyalty to and retention with their health plan.  That says a lot about the state of the member experience in MA despite the priority and focus.  It says we’re missing the point.

Meanwhile, Alegeus Technologies had some incredible findings in their annual health plan consumer survey presented at the recent AHIP conference.  First, they found half of members (50%) do not want to “play an active role” in their healthcare. This argues plans’ investments in “member engagement” may be backfiring with half their enrollees. And there was widespread confusion in what they’re paying for, possibly delineating why appeals and grievances processing remains the top compliance challenge for plans:

• 66% of members think they’re not paying the right amount
• 56% complain they don’t know how much they are spending until after they receive services
• 45% of members say they simply do not know much they spend even after getting a bill
• 45% say they never know what is covered

All of this says the way we think of and invest in the “member experience” needs rethinking.

It reminds me of the seminal 2014 behavioral economics study that found that happiness is defined by expectations being exceeded a little bit on a regular basis.  Because expectations are variable, everyone can be made happy.  That begins during the marketing and sales process and continues throughout the member lifecycle.

Moving to proactive service models is only the beginning. Only half our members want to be involved — the rest are disappointed and confused enough to be leaving in growing numbers to join inferior and more expensive products. They need help navigating provider networks, better understanding of how to use their benefits, and what to expect in out-of-pocket spending in real time. They need in-plan service ninjas empowered to solve their problem on the first call. They need Pharmacy Benefit Managers to get it together and health plans to advocate and agitate for members with their vendors. They need constant improvement in the member experience to be the new normal in government programs.

Resources

For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year’s information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn’t. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>

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