Coauthored by Adam Higman, Payer Consulting
Improving the patient and member experience is a hot topic right now, due in part to changes from the Centers for Medicare & Medicaid Service (CMS) to the Star Ratings system. Revisions made in 2020 put an increased emphasis on health plans to improve the member experience—or risk losing millions of dollars in quality bonus payments.
But what do these changes mean for provider-owned health plans—more commonly known as “payviders”?
Previously, Star Ratings were based on clinical care and health outcomes. But experience now takes the top priority, with 34% of a health plan’s rating based on scores from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey through Stars 2025. However, CMS released a proposed rule in mid-December that, if enacted, would reduce the impact of CAHPS on the Stars 2026 rating by half. Under this proposed rule, it will still be important for health plans and providers to focus on member experience. CAHPS will remain the backbone of the Stars program, as happy engaged members are more willing to get preventive care, visit their healthcare provider, self-manage chronic illnesses, take medications as prescribed, and stay enrolled in the health plan. The CAHPS survey looks at an individual’s experience with their healthcare provider as well as with their health plan. Because many health plans offer financial incentives to their network providers for helping them achieve a 4- or 5-star rating, these changes have health plans and providers seeking new ways to work together to improve the patient experience and, in turn, achieve a higher Star Rating.
Payviders, however, have a unique advantage when it comes to improving Star Ratings, typically having a high health plan membership concentration in their employed medical groups. Because the healthcare provider or organization owns the health plan, it has a vested interest in ensuring the plan achieves at least a 4-star rating. Millions of dollars are at stake for health plans, and for the provider group that owns the plan.
How are Star Ratings measured?
Medicare Advantage plans with prescription drug (Part D) coverage are rated based on 38 unique quality and performance measurements across five main categories, plus four Part D categories.
- Staying healthy: A health plan is rated based on its members’ access to preventive services like physical examinations, annual screenings, and routine vaccinations.
- Managing chronic conditions: Health plans are evaluated by how often members with chronic conditions—such as diabetes, cardiovascular disease, and arthritis—receive services or treatment to manage their conditions.
- Member experience: Health plans are rated based on members’ experience with the entirety of their care—including care from doctors and physician practices.
- Member complaints: A health plan is evaluated by how frequently members submit complaints, whether members choose to leave the plan, and whether performance improves from one year to the next.
- Customer service: Health plans are rated on how well they respond to customer requests.
- Drug plan: The four Part D categories include measures around drug plan customer service, complaints, experience, medication adherence, and pricing/safety.
A plan’s Star Rating determines its reimbursement. For a health plan with 40,000 Medicare Advantage members, jumping from 3.5 stars to 4 stars could mean nearly $20 million in reimbursements to payers. Moving from 4 stars to 4.5 stars—just a half-star increase—can bring in an additional $8 million. Achieving a 5-star rating means a health plan can accept new members all year long, instead of just during open enrollment.
Looking at patient experience and member experience data holistically
At Press Ganey, we work with health plans that cover 98% of enrollees across the United States. Many health plans have hired Press Ganey to provide consulting services to their network providers to help improve the patient experience.
Consider, for example, Kaiser Permanente (KP)—the largest provider-owned health plan in the United States, with more than 12 million members. Our technology integrates KP’s member experience data with its patient experience data and identify key drivers of Star Ratings. This lets KP look at things more holistically and leverage its internal resources in the most efficient way possible.
Improving the patient and member experience
In a recent article, my colleague Aaron Fausz wrote that “a patient’s interactions with both the provider and the payer inform the overall experience.” For payviders (and all other health plans and providers), it is imperative that the provider network and payer group work together to improve the overall experience.
One of the primary ways to do this is to use data to identify key drivers. Both patient experience data and member experience data can help payviders identify what's negatively impacting scores and determine where to focus on improvements. Scheduling appointments, feeling as if the doctor listened carefully, feeling respected, and access to care can all impact a patient experience score. On the payer side, long wait times to talk to customer service, a lack of empathy from agents, and frequent unexplained health plan policy and negative benefit changes can impact member experience scores.
The payer and provider side of house can effectively work together to impact drivers around helping patients/members anticipate out-of-pocket costs, preauthorizations for diagnostics/procedures/specialists/drugs, and new member onboarding. Payviders can also better understand variation in the member/patient journey across care settings. Of particular importance is understanding variation in experiences across employed vs. aligned vs. network physician groups where challenges may exist with non-employed providers outside of the provider’s core service area. The highest-performing payvider organizations ensure aligned incentives for member experience performance across these groups through value-based arrangements.
Because payviders are owned by the health system, they're also able to take a more integrated approach to care coordination. This integration can improve transparency related to improved information sharing, appropriate follow-up, and better communication.
Our team helps payviders stay a step ahead of the game. Get in touch to learn more.