Part I – This is the first part of a two-part blog series.

By 2060, 95 million seniors will be eligible for Medicare (U.S. Census Bureau), nearly a 70% increase in the number of those eligible today. Americans aren’t just aging, they are living longer AND living longer with multiple chronic conditions.

Today, health plans are faced with the challenge of achieving outcomes based on quality, performance, and now the customer experience—factors that feed into a health plan’s Star rating. As such, the pressure is on to create and deliver an optimal member experience at every point in the member journey.

Star ratings do matter. According to CMS, 77% of all Medicare Advantage plan members are enrolled in plans with a four- or higher- star rating. If a health plan cannot hold a four-star rating, members switch to a higher-rated plan. When health plans lose a star, this is an opportunity for other health plans to pursue new members aggressively. Disenrollment is a true pain point for health plans.

Let’s take a look at three key areas impacting the member journey and ultimately Star ratings: medication adherence, the customer experience, and CAHPS surveys.

Medication Adherence

According to a 2019 Kaiser Family Foundation report, seniors said affording their medications and taking them as prescribed is difficult.

Nearly 80% said their condition worsened due to not taking their medications.  And, unfilled prescriptions lead to an increased risk of patients going to the ER, along with the chance of costly hospital readmissions. With the increase in weighted measures for medication adherence, improving medication-related behaviors goes beyond simple reminders to refill prescriptions.

Medication adherence is absolutely critical to Star ratings.

According to the American Journal of Managed Care, the CMS May 2020 rule on improving the customer experience and medication adherence measures will have a direct and near-term effect on a health plan’s Star rating. This rule also emphasizes using engagement tools to keep members in-network and reduce out-of-pocket expenses.

Customer Experience

Medicare Advantage is growing quickly and, in fact, is the fastest-growing business line for many health plans. How members engage with their health plan is reflected in the Star rating.

Since the consumer experience is now a business and performance imperative, the weighted measures for experience are increasing, making up more than 50% of Star ratings for the first time. Member experience and complaint measures are quadruple rated for PY 2021, and for PY 2023 these measures will account for 54% of ratings, shifting the scales over all other measures. (CMS)

CAHPS Surveys

The CAHPS survey asks members questions about their experiences with their providers and health plans. Fifty percent of experience measurements are determined by CAHPS questions. These questions take into consideration “perceptions” of the quality of the care they received. Members’ perceptions via surveys can count for AND against health plans.

And, experience does not equal satisfaction, according to CMS.

CAHPS surveys want to know the member’s opinion of the experience, not if they were satisfied. Experience and satisfaction may be similar, but they are different. People can be okay with their experience and still not be happy or satisfied with how the experience turned out.

Health plans are feeling the pressure to think beyond what it takes for a member to act and consider what it will take for a member to become engaged. Simply asking members about their experiences are opportunities to connect members to the resources and help they need. It will be necessary for health plans to connect with members who struggle in areas specifically measured by CAHPS and develop those member relationships early.

Of note is that many health plans have faltered in the past year because they focused on Stars separately from HEDIS interventions. However, these measures are interrelated and coordinated interventions between the two will drive better progress and results.

Now that we understand a few of the tough challenges health plans face, in Part 2 we will uncover the solutions critical to ensuring members are connected to their health plan at each point in the member journey—solutions that will ultimately help deliver higher Star ratings.


CAHPS and Medication Adherence Now Dominate Medicare Advantage Star Ratings

New Stars ratings for Medicare Advantage prioritize customer experiences

High-quality care for Medicare Beneficiaries Continues as Medicare Health and Drug Plans Receive Star Ratings