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It’s Time for Medicare Advantage and Part D Plans to Elevate Consumer Experience and Medication Adherence


Jason Rose, CEO, AdhereHealth

Medicare Advantage Prescription Drug Plans (MAPD) now have even more reason to put an emphasis on consumer experience. The Centers for Medicare & Medicaid Services (CMS) announced a new Medicare Advantage Star Ratings formula for contract year 2021, and the changes will quadruple the weight of CAHPS (Consumer Assessment for Healthcare Providers and Systems)—surveys asking consumers about the experience with their health and drug plans. 

Under the updated weighting methodology, CAHPS measures will represent 32% of the overall Star Ratings. In addition, 52% of the weighting is already based on medication-related measures. Taken together, medication-related and Consumer Experience measures will drive more than 80% of Star Ratings for the 2021 contract year.

Star Ratings have always mattered to a health plan’s bottom line, and now CAHPS performance will be that much more important. MAPD plans that fall below the 4-star threshold could lose out on reimbursements from the $7 billion Quality Bonus Payment  pool—to the tune of approximately $500 per member per year. 

Not all plans will weather the weighting shifts equally. Today, the majority of plans perform well. In 2020, 78% of enrollees are in plans with at least a 4-star rating. However, deeper analysis reveals Dual-Eligible Special Needs Plans (DSNPs) perform quite differently. Only 70% of the nearly three million DSNP enrollees are in at least a 4-star plan. Whereas CMS adjusts quality and adherence measures for DSNPs, these adjustments do not create a curve for CAHPS measures. As a result, the CAHPS weighting shift to four times in 2021 will likely have a tremendous negative impact on DSNPs. 

Still, even plans that currently perform well will face an uphill climb under intensified expectations. The Star Ratings bonus pool is finite, and the new framework creates a downward spiral. If plans miss out on these bonus earnings, there is significantly less money to invest in necessary improvements. Further, beneficiaries will choose plans with richer benefits, and as such, the membership size will be negatively impacted. This cycle could create an existential threat to plans that do not fully embrace and excel at the consumer experience measures. 

For plans to thrive in the new weighting, they will need to address comprehensive engagement approaches for medication-related initiatives and consumer experience. As CAHPS surveys are collected between March and May each year, plans must begin implementing the updated engagement approach now. 

How To Improve Consumer Experience 

Consumer perceptions of their health plan are created by multiple impressions accumulated over time. When given the opportunity, how positive and thorough was their experience with the plan’s customer service? Was their physician care focused on overall understanding of individual quality needs? What was their experience with the plan’s pharmacy choices? These and every other encounter contribute to overall consumer experience.

As a matter of critical importance, plans must address CAHPS measures as part of their routine consumer engagement. The consumer experience approach needs to become a year-round focus integrated into other quality improvement activities—most notably, those focused on medication-related measures. Here are three strategies to ensure success.  

  1. Organize the plan around the consumer, not the quality measure itself. For every health plan department that directly or indirectly affects members’ experience, there must be an organized and cohesive strategy. Most health plans, particularly the larger national plans, are not organized in this manner.  Consumer “journey” mapping or communications audits can help leaders understand and improve the range of consumer touchpoints. Plans should invest in customer relationship management (CRM) tools and approaches to increase efficiency and effectiveness of every contact. The CRM should use predictive analytics built into the clinical workflow tools that provide for near real-time understanding of what the clinician should be focusing on addressing on the individual consumer journey.
  2. Conduct root-cause analysis to address Social Determinants of Health: Plans should proactively investigate what keeps their members from accessing needed care, filling prescriptions, or adhering to treatment plans. Whether a consumer can easily access needed care or follow treatment plans may be rooted in nonmedical barriers, such as lack of health literacy, transportation, or trouble affording copayments. If a member has a ride to and from a medical visit but not to the pharmacy on the way home, a vital prescription may go unfilled. COVID-19 has only exacerbated consumers’ nonmedical challenges, creating greater need for plans to work with high-risk members. CAHPS surveys should be scrutinized to reveal the real drivers of plan performance, leveraging predictive analytics that is integrated data across the plan. Lack of understanding of the health plan benefits and/or health literacy issues often the cause of these barriers to care.
  3. Reduce consumer hurdles to improving care. Strategies for managing medical and pharmacy expense may at times be at odds with outstanding consumer experience. The new Star Rating weighting formula may change that equation and could elevate opportunities to reduce undue barriers to care. For example, copayments on drugs for chronic conditions may reduce medication adherence whereas removing them may improve adherence levels and raise consumer experience scores. Aligning health plan policies could help plans improve consumer experience, medication adherence, and unnecessary cost of care. 

The Consumer Experience Imperative 

Consumer expectations typically only increase over time. CMS has already signaled their intention to incorporate a net promoter score into future Star Ratings. These incremental changes will continue to raise the bar on MAPD plans. 

For plans to meet these expectations, they must use each encounter, call, or contact to improve consumer experience. Every process, policy, and procedure can improve—or detract from—consumer experience. 

A key to success is using robust analytic tools that enable plans to strategically engage with consumers proactively, year-round with a data-driven clinical workflow architected through a CRM platform. This systems-driven approach will enable plans to build on effective medication adherence programs and continuously improve consumer experience to optimize Star Ratings.  

Put simply: Leveraging technology to do the right thing for consumers will position MAPD plans for an ever increasingly consumer-driven future. 

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