Improving the consumer experience is top of mind for nearly every industry, and healthcare is no exception. Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates Medicare Advantage plans based on a 5-star rating system. Health plans that score 4 stars (above average) or 5 stars (excellent) are eligible to receive a quality bonus payment from CMS.
Since the inception of the star rating system, a plan’s star rating was heavily weighted toward clinical care and health outcomes—goals that were straightforward to measure and achieve with the right tools. In 2020, however, CMS began to revise its star rating system to shift more weight to the patient experience (PX).
These changes have brought together payers and providers to work toward several shared goals: an improved patient (or member) experience, greater patient satisfaction, and higher star ratings.
Millions of Dollars at Stake for Payers and Providers
Significant bonus payments are at stake for Medicare Advantage plans—and their providers’ performance will ultimately determine their overall rating. Between 2015 and 2021, the total annual bonuses to Medicare Advantage plans nearly quadrupled, increasing from $3 billion to $11.6 billion.
Historically, payers have incentivized providers with financial bonuses if mutually agreed-upon quality levels and clinical outcomes were achieved. For example, UnitedHealthcare, the largest health insurer in the United States, has the Quality-Based Physician Incentive Program, which provides network physicians the opportunity to earn an incentive payment if they perform clinically appropriate procedures and meet certain quality standards. Similar provider incentive programs are also available through Anthem, Blue Cross Blue Shield, and other large health plans.
Now, with the shifting focus toward PX, it is imperative that health plans encourage network providers and practices to take steps to improve the patient experience. Changing incentive plans to reward providers who meet agreed-upon patient experience measures is one way to do this.
Measuring the Patient Experience
Without measurement and data, it’s impossible to know what quality looks like as it relates to the patient experience.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a universal tool that helps payers better understand patients’ experiences with health plans and their services. CMS uses this survey to dictate star ratings for Medicare Advantage plans. But it’s also critically important for payers to drill down deeper and measure the patient experience at the provider level. With this data, it’s possible to know which providers are performing well and which providers are struggling to keep up.
One way payers can get this data is through funding the distribution of PX surveys for their in-network providers. For example, Press Ganey’s PX post-visit survey is a good indicator of CAHPS scores.
In fact, Press Ganey’s national study of PX surveys revealed that there are a few ties between provider performance and star ratings. For example, 65% of top performers on the “ease of scheduling appointments” question achieve 4+ stars on the CAHPS Rating of Health Plan. In the official CAHPS survey, 70.7% of top performers on the “ability to have routine appointment/checkup as soon as needed” question achieve 4+ stars (figure 1).
Figure 1. Relationship between provider performance and star ratingsClick here to enlarge.)
Payers can use the data obtained through patient experience surveys to determine what measures to grade providers, medical groups, or hospitals on. For instance, a payer might hold its network providers to these agreed-upon standards for patient experience:
- Patient “always” got answers to medical questions the same day they contacted the provider’s office
- Patient “usually” or “always” got appointment for non-urgent care as soon as needed
- Provider “always” explained things in a way that was easy to understand
- Provider “always” showed respect for what the patient had to say
- Someone from the provider’s office “usually” or “always” talked about all prescription medications being taken
- Clerks and receptionists were “usually” or “always” courteous and respectful
With the increased emphasis on the patient experience, the need for collaboration between payers and providers has never been greater. Giving providers compelling incentives to pursue the shared goals of an improved patient experience and greater patient satisfaction (and, ultimately, a higher star rating) is in everyone’s best interest.
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