The Centers for Medicare and Medicaid Services (CMS) use a five-star quality rating system to measure Medicare beneficiaries’ experience with their health plans and the health care system. This rating system applies to all Medicare Advantage (MA) lines of business including: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-For-Service (PFFS), and Prescription Drug Plans (PDP).
The member perception measures are centric to the Star ratings being 23% of the total weight of the overall measures (11 out of 47). This makes sense, as CMS is increasingly moving to tie reimbursement for Medicare services directly to patient outcomes. But this also makes it essential that health plans place adequate emphasis on the member perception measures.
That is easier said than done. How can you place yourself in the member’s seat? With so many variables in a member population, how can you begin to understand them, let alone predict their needs?
The challenge is in collecting useful data from perception-based surveys; data that can provide insight into personalizing and improving member engagement.
The data collection process for Star ratings comes from annual member surveys for Consumer Assessment of Healthcare Providers and Systems (CAHPS), which gauges the member’s perception of provider accessibility and the Health Outcomes Survey (HOS).
In addition to being primarily perception-based data, other complexities surface with this process:
- Complex member eligibility guidelines
- Survey sampling criterion (small sample size and a bit of luck)
- Member response rate (responses relying on member’s mood and also a bit of luck)
- Case mix adjustment (to account for every health plan or every member).
Because of the uniqueness and complexities of health insurance plans and their members, there is not a one-size fits all solution. To overcome these obstacles and gain access to insightful information that will ultimately improve ratings, you need a member-centric plan.
Every member experience is unique, and therefore the health plans should work to personalize every member experience. But the reality is, most health insurance plans currently do not have a member-centric approach/view to improve the way they engage and inspire their members. This causes significant abrasions and a negative perception, which in turn adversely affects quality ratings.
Improving the member’s experience means adopting a member-centric approach, having the member at the center of all interaction. Here’s how to get started:
- Take an individualized approach to member engagement. View the member as a person with expectations and needs beyond being a member of a plan. Today, members can have different tastes and preferences in how they want to be engaged.
- Engage the individual at every touch point. This requires highly effective omni-channel alignment with individual preferences.
- Ensure that every interaction is effective by constantly measuring and managing – beyond campaign management.
- Move past typical reporting into predictive and forecasting techniques in order to measure individual perceptions, interaction management, measure performance, and financial performance.
- Perfect the coordination of campaigns and leverage data and other predictive techniques to anticipate calls.This can be solved with a platform-integrated solution of self-service systems for members, CRM systems for the health plan, and fulfillment services. More specifically;
- Member portals for self-service (care plans, preference management, communications)
- Member-centric CRM tools for health plan administration (care gap management, campaign management, preference management)
- Robust analytics for reporting, predictive and forecasting performance, measure performance, and individual member segmentation/targeting. Health plans aren’t there yet, but those that effectively translate data into output are winning and will continue to win.
- Create the optimal next best action for both the member and the plan on how they engage, so that it’s a delightful experience for the member.
- Ensure alignment and compliance with operational policy and process that positions the individual at the center, therefore, better serving the member and, most importantly, managing their expectations.
As mentioned above, every health plan is as unique as each member. This mixes in some complexities when it comes to improving members’ perspectives and overall Star ratings.
Contact SDLC Partners to develop a specific member engagement strategy and improve overall performance.