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A journey to the stars: 5 key strategies of top-performing health plans

Since 2007, Medicare has provided an evaluation and incentive system to align what patients want (easy access to great care) with the insurance products that facilitate that care. When Medicare initially launched its star system for Medicare Advantage plans, it focused on the clinical processes of care. As a result, measures on safety and quality have steadily improved.* But the Centers for Medicare and Medicaid Services (CMS) recognizes that the experience of care is critical to driving the best possible healthcare outcomes. The experience of care is so foundational to the population’s perception of healthcare quality that, over the years, CMS has significantly evolved its star measurement system. Today, over 75% of the drivers making up Star Ratings are influenced by users’ experience using either their health benefits or the healthcare services that those benefits support.  

The Press Ganey consulting team leveraged our extensive database comparing what 5-star plans do vs. average-performing plans. We found five critical levers that high-performing plans focus on. 

5 key actions of high-performing plans

1. Lead from the top: 5-star plans develop proven strategies and roadmaps to ensure performance is led across the C-suite, is tied to executive dashboards, has focused resources, and uses organization-wide bonus pools leading to sustained performance.

2. Leverage intentional benefit design: Benefits are structured to simplify access to care through VBC arrangements minimizing barriers to treatment (including prior authorizations and utilization management), incentivizing care gap closure, and making cost sharing predictable. Brokers have incentives to understand the benefits and earn competitive commissions for appropriately matching the plan with clients.

3. Partner with providers and suppliers: Contracts with provider groups and physicians include upside for hitting access, experience, and quality targets; embed two-way communication between health systems/physicians and plans to ensure effective ongoing relations; and offer at-the-elbow support for critical partners. Pharmacy and dental providers, along with key vendors, are contracted to include data sharing, care coordination, and SLAs for PX and MX performance.

4. Make key touchpoints count: New members are welcomed with white-glove service and streamlined enrollment processes, and further supported by intuitive tools to help navigate their benefits. High-performing plans ensure the provider directory is accurate and up to date, offer omnichannel access to customer service, and simplify the member financial experience with over 90% of claims auto-adjudicated and less than 5% denied.

5. Leverage 21st-century listening and analytics: In addition to strategic outreach and surveys, high-performing plans use multimodal listening systems with NLP-based sentiment analysis and segmented focus groups, teasing out demographic variations in experience. Effective predictive analytics help target interventions with the highest potential for impact. The data is used broadly for effective, continuous learning and performance improvement with strong partnerships between CAHPS strategy, consumer experience, and marketing stakeholders. Reliable operating systems are driven through this data strategy, reducing administrative burden on members and providers, eliminating friction points in getting needed information, and reinforcing moments that matter.

Press Ganey is a valued partner for health plans on their path to improve star performance. In 2022, we partnered with Forsta to create a comprehensive listening system on key drivers of the member care experience. Our Human Experience platform ingests and analyzes quantitative and qualitative information from across the healthcare ecosystem, presenting insights with intuitive visualization tools that help plans and providers identify critical actions needed to move performance. The Press Ganey consulting team not only helps organizations turn those insights into action, but they also help organizations hardwire in reliable results. Our team supports development of the overarching C-suite-level strategy, design, governance, process reliability, and measurement critical to moving an organization forward.

At Press Ganey, we believe the Human Experience of care is foundational to optimizing the future of care delivery. Advancing performance on the Medicare star program is one way to do the right thing for the business of running a health plan (contributing to the brand reputation, revenue, and membership growth) while doing the right thing for the patients served—optimizing outcomes for all. Together, health plans and Press Ganey serve to make lives better. Let’s make it happen.

See for yourself why thousands of healthcare organizations partner with Press Ganey. Learn more here.

*Improvement trend was disrupted during pandemic years.

About the author

Amy is an internationally respected physician, executive, innovator, and author. October 2022, she became President at Press Ganey, focusing on simplifying health and care. Until September 2022, Amy was President of Clinical Care at Providence, responsible for clinical operations and care, including improving health, care, and value outcomes delivered by the 52 hospitals, 1,085 clinics, and 120,000 caregivers of the $25 billion health system. She was instrumental in Providence’s early adoption and scaling of technology advancing the future of healthcare. Before joining Providence in 2015, Dr. Compton-Phillips spent 22 years at Kaiser Permanente, moving from a front-line internist to ultimately serving as Chief Quality Officer.

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