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Patient and member experience: 2 sides of the same coin

In 2020, the Centers for Medicare & Medicaid Services (CMS) made a game-changing revision to the Medicare Advantage Star Ratings system, a quality rating that evaluates Medicare Advantage plans and rewards them with a bonus payment for achieving at least 4 or 5 stars.

Since their inception, Star Ratings have been weighted heavily on clinical care and health outcomes, but now, patient experience (PX) is taking the top priority. Once the new weightings are in place in 2024, 34% of a plan’s rating will be based on scores from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey—a survey that evaluates an individual’s experience with their care provider as well as their health plan. Simply put, a portion of a plan’s score will be dependent on the performance of its network providers.

So, how can health plans ensure they achieve a 4- or 5-star rating when much is dependent on a provider’s performance and focus on patient experience? For starters, collaboration between payers and providers is critical. This relationship has long been stereotyped as adversarial and tumultuous, but most healthcare providers are open to using solutions from health plans. And with millions of dollars in quality bonus payments on the line, these groups have a vested interest in working together to make changes.

The bottom line is that health plans and providers alike have been entrusted to provide the best experience possible for patients—as well as for each other. Their efforts represent two sides of the same coin: A patient’s interactions with both the provider and the payer inform the overall experience—and that experience can often be a factor in their actual health outcome. The timely sharing of information, both clinical and administrative, is essential to keeping all parties aligned behind their shared goal. The change in the Star Rating weights simply raises the financial stakes, providing added incentive for what should be happening anyway.

3 strategies to help providers improve PX

I already shared how payers can use surveys and data to measure the patient experience and incentivize top-performing providers. This data can also identify providers who are struggling to meet PX standards. Fortunately, health plans can implement a few strategies to help their network providers improve the patient experience.

  1. Identify key drivers of negative scores. Using survey data can help payers identify which providers and practices are struggling—and what specifically is negatively impacting scores. Access to care, coordination of care, customer service, and even the atmosphere of the clinic or facility can all impact a provider’s patient experience score. Identifying these drivers can help payers—and providers—determine where to focus their improvement efforts.
  2. Provide training and coaching for providers and practices. Many large payers are offering to pay for provider-intensive and practice-intensive training for low-performing providers and groups. Press Ganey’s strategic consultants offer customized interventions and training programs based on the organization’s unique needs. Through in-person and/or virtual meetings, our consultants can help providers and staff understand how culture, processes, and service behaviors impact the patient experience—and offer recommendations on where to improve.
  3. Streamline and automate processes that lead to delays in getting necessary care, tests, or treatment. Prior authorization can be a headache for providers and patients. A 2021 survey from the American Medical Association revealed that physicians and their staff spend nearly two business days each week completing prior authorizations. Although prior authorization is often necessary, the manual process can lead to delays in care and create unnecessary red tape. Payers can help alleviate the burden by reevaluating the services that need prior authorizations, leveraging electronic tools to automate the process, and proactively sending status updates to providers to keep them up to date on authorization status.

3 key steps to improve member experience (MX)

Although more than 70% of the CAHPS survey focuses on an individual’s experience with his or her doctor, there are questions about how the individual interacts with the health plan—meaning payers must also focus on improving this experience too. Here’s how.

  1. Make customer service a priority. Long wait times to talk to a customer service agent, high levels of stress trying to get issues resolved, and a lack of empathy and compassion from health plan customer service agents can negatively impact MX scores.
  2. Engage with members. Use analytics-grounded insights to target and coordinate member outreach and design loyalty and retention strategies.
  3. Close gaps in care. Health plan care managers can help walk members through their healthcare journey, ensuring collaboration and continuity of care along the entire journey. Emphasizing preventative care not only improves patient health and experience, but it reduces costs for health plans in the long run. These efforts can help members feel empowered to take an active role in their health as well as feel valued by their plan, both improving outcomes and building loyalty.

In 2021, Press Ganey acquired SPH Analytics, combining Press Ganey’s industry-leading patient experience data with SPH’s robust member experience data—and bringing powerful insights to the once-fragmented provider and payer landscape. Press Ganey’s strategic consulting team works with payers and providers alike to address the biggest challenges that organizations face today. We can leverage your data in concert with our solutions and analytics to design and implement a uniquely tailored plan. Reach out to an expert.

About the author

Aaron leads engagements for the Payer solutions team in Strategic Consulting, partnering with clients to find and fill the gaps in their organization and their teams, and get patients and employees more engaged. He helps clients identify and utilize their strengths to drive improvement. Aaron has more than 30 years of experience helping various healthcare organizations grow and improve. He’s written two books: ”Leading Healthcare Improvement: A Personal & Organization Journey” and ”Healthcare Is Killing Us: The Power of Disruptive Innovation to Create a System that Cares More and Costs Less.”

Profile Photo of Aaron Fausz, PhD