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How the New CMS Final Rule will Change Medicare Member Engagement

On Friday the Centers for Medicare and Medicaid Services (CMS) issued a Final Rule that included confirmation of a number of big changes to Medicare Advantage and Part D Star Ratings that were proposed back in February. These changes will have a big impact on Star Ratings engagement strategies. Among other updates codifying existing policy and contracting rules for Medicare, CMS is going forward with tweaks to the quality measurement system that can dramatically impact plan ratings and performance. CMS is estimating that these changes alone will result in a reduction in $3.65 billion in federal spending in the next decade by tightening Star Rating methodology. But beyond the immediate financial impact, the rule means plans will need to ensure they have a competitive engagement strategy around Member Experience and invest in building relationships with their members now.  

So what is changing in Star Ratings for Part C and D?

1. Patient experience and complaint measures will be quadruple-weighted.

This change means that measures from CAHPS and the rest of the category will now be the most influential part of overall and summary measure calculations. Measures like Getting Needed Care will now impact an MA-PD plan more than the Medication Adherence or Outcome measures – their triple-weighting no longer the highest among the non-Improvement measures. The jump from the current 2x weighting to 4x will mean that member responses to CAHPS questions about access and satisfaction will be major determining factors in plans’ overall ratings for the 2021 measurement year.

2. CMS is moving to reduce the impact of outliers on Star Rating cut points.

By using a process called Tukey outlier deletion, CMS will remove plans with measures that are statistically outlying from the calculations that determine rating cut points. This means that plans that are doing abnormally well or poorly on a measure will not exert extra influence upward or downward on the “curve” that determines the rating for all plans. This is where CMS projects to reduce spending. The most likely effect of outlier deletion will be to remove lower-performing plans and increase cut points – which will likely reduce the number of plans receiving higher overall ratings and the bonus payments that come with them. CMS is delaying implementation until the 2022 measurement year due to the COVID-19 outbreak, giving plans some additional time to assess the impact and prepare.


What does this mean for Medicare member engagement?  

mPulse Mobile partners with Medicare plans that cover over 56% of all MA lives and our technology powers conversations with millions of members every month. Here’s what we are seeing and hearing about the changes to Star Ratings: 

Engagement strategies must center around CAHPS, not just include it. 

Most engagement strategies that seek to improve Star Ratings tend to focus on outcome and process measures, where specific member actions are vital to success. Engaging members about refilling prescriptions, completing important screenings, and managing chronic conditions to impact HEDIS and Medication Adherence-based measures has been the primary approach for many plans for years. Plans now must think beyond the action-based use cases and think about engagement as a core part of relationship-building with their members. CAHPS-specific solutions, such as off-cycle surveys or conversational follow-ups after provider visits are moving to the forefront in our customers’ strategies. Simply asking members about their experiences at scale can both provide powerful insights and opportunities to connect members to more resources and help. Plans are using automated conversations and data analytics to measure sentiment and intent of member responses to text messages to find “hotspot geographic areas and “hot topics” where negative (or positive) sentiment is clustering.  We are also seeing more customers use Conversational AI and our browser-based Engagement Console to enhance existing member services team efforts to provide concierge-level help to members, as plan navigation becomes more important to boosting member experience.  

But plans cannot ignore the unchanged measures. 

Medication Adherence and HEDIS are still going to have a major impact on overall ratings. So as plans correctly look to focus more resources and effort on Experience and Complaints measures, they also need to find ways of achieving or maintaining high ratings in those areas efficiently and at scale. For our customers, that has meant using Conversational AI-enabled outreach to deliver automated prescription refill dialogues or start tailored conversations designed to help close gaps-in-care. And since these are really conversations – with members welcomed to respond back – we can actually hear about barriers, difficulties, and frustrations members may experience in completing those actions. That data is invaluable in helping shape and refine a CAHPS strategy. Because an experience-centric strategy makes every member touchpoint – even a refill reminder – an opportunity to learn from and connect with the population. 

One thing does not change: Stars continue to drive the engagement strategy. 

The outlier deletion process will have a wide impact. For engagement, it means that Stars will become even more competitive, and deploying solutions that make a real impact will move from being a goal for most MA plans to an absolute necessity. Outreach that can reach people at scale and still provide a personal, conversational experience will be crucial, as will finding ways to reach members who aren’t engaging with existing channels. mPulse is seeing plans get on the front foot: proactively starting conversations with their members about their benefits and health at massive scale. And with the COVID-19 crisis, these plans are finding members especially eager to learn about their healthcare and how their plan can help them. Building that relationship now will help these plans down the road, when they need to activate members to close a care gap, or when a member who received a tailored and helpful text message receives a CAHPS survey months later.  

Only The Lonely…Social Isolation in the Modern World

A healthy mind in a healthy body is a phrase that’s been around for two millennia (an ancient Roman is credited with it).  Originally meant to convey faculties we should aspire to, it later came to capture the interdependence of mental and physical wellness.  The ancient Romans had an imperfect understanding of this fragile equilibrium compared to today, but many of the same factors that conspired against the ancients and a healthy mind-body equilibrium still threaten us.  One of the most insidious is loneliness.

The COVID-19 pandemic has also coined a phase—social distancing.  This lesser of two evils has limited social interaction and left us, temporarily, in a lonelier world. It has also weakened the social support structures we previously took for granted, and which help sustain a ‘healthy mind in a healthy body.’ The Disaster Distress Helpline at the Substance Abuse and Mental Health Services Administration saw an almost nine-fold increase in calls in March 2020 compared to a year ago. Troubling as this trend is, it may also be something of a red herring.

Isolation—perceived or actual—is an omnipresent risk and chronic, long-term reality. According to a 2018 national survey by Cigna, levels of loneliness have reached an all-time high,  with half the 20,000 surveyed reporting “they sometimes feel alone.” The Health Resource and Service Administration reports that a quarter of the U.S. population and almost one-third of older adults lives alone, and this number has been rising over the last decade.  A recent meta-analysis published in the Monitor on Psychology of the American Psychological Association, determined that a lack of social connection heightens health risks “as much as smoking 15 cigarettes a day or having alcohol use disorder.”

Typical consequences of chronic loneliness include cardiovascular disease, chronic depression and attendant risk of suicide; also cognitive decline, Alzheimer’s disease, and an overall, elevated risk of mortality.   The meta-research further suggests, “chronic loneliness is most likely to set in when individuals either don’t have the emotional, mental or financial resources to get out and satisfy their social needs or they lack a social circle that can provide these.”

The current pandemic has doubtless highlighted the issue of loneliness, and this silver lining  may yet prompt structural changes in healthcare and perceptions of what it is to be isolated.  For now, the Coronavirus Preparedness and Response Supplemental Appropriations Act 2020, which was signed into law on March 6, has expanded digital and tele- mental health services in order to prevent further decompensation (inability to summon up psychological coping mechanisms) and avoid potential consequences like suicide attempts, emergency department visits and need for psychiatric hospitalizations, in a resource-constrained environment.

Beyond the pandemic, it is likely that longer-term support frameworks will be needed. Psychiatrist Damir Hueromevic, who co-authored the (prescient) 2019 book Psychiatry of Pandemics: A Mental Health Response To Infection Outbreak, is one of many commentators with a cautionary note. The book warns the secondary effects of the pandemic such as recession, social unrest and unemployment, could trigger widespread and ongoing mental health challenges.

The difficult truth is that even a nominal end to the “social distancing” will not necessarily end the isolation issues it engenders.  In fact, Science News reports that even relatively shorter-term isolation can lead to longer-term psychological problems, consistent with post-traumatic stress. Some studies even hypothesize a chemical “switch” that is flipped during longer-term isolation.  A team of researchers at Caltech demonstrated over an extended series of studies that prolonged social isolation in mice could lead to physical changes in the structure of the brain’s neuroreceptors.  This caused behavioral changes, including increased aggressiveness and persistent fear.  Such responses remained “frozen in place” long after the isolation ended. Humans possess a similar physiological brain chemistry to the areas impacted in the mice.  Other human-based studies suggest that isolation can be recursive. Being isolated and lonely can further weaken the motivation and ability to engage with others, leading to still greater isolation… and so on.

The physical and mental effects of loneliness and social detachment may be unsurprising given what we know about the mind and psychosomatic illness. What might surprise, however, is a significant remedy.  In the context of mitigation, “giving” can actually be better than “receiving.”   Research on those suffering from loneliness affirms that by helping others, not only can the “giver” gain the benefit of a social network, but gain a sense of purpose. This altruistic behavior, according to findings presented in Scientific American  creates a valuable social bond with others and stimulates the mind to build neural connections which make the brain more resilient to cognitive decline and dementia-related diseases, like Alzheimer’s.

While on the subject of giving versus receiving—if you’re reading this article and work for a provider, managed care plan or other organization vested in caregiving, here’s some news that might resonate: Helping others and doing so effectively not only helps your member population, but can also improve employee productivity.   A wide body of research – collectively called the “Happy Worker Thesis” – demonstrates that happy people are more productive.  A recent study of call-center employee productivity described a strong causal effect of happiness on sales and other key interactions. mPulse Mobile understands this premise well.

The mPulse Mobile Engagement Console – the browser-based UI that lets staff manage text interaction with members – is designed to give staff more capacity to focus on higher-order, more valuable and satisfying interactions instead of spending time outbound calling or answering simple questions. Research also supports the flip side of the happy=productive equation. Productive people, like your employees, tend to be happier.  Why? Because being productive can translate to a greater sense of purpose, which improves self-esteem.  It can also enhance mental satisfaction and the release of endorphins.

Finally – as you address your own challenges including those of the “new normal” – know you aren’t alone. mPulse is a leader in engaging consumers about healthcare challenges and how they change relative to public health issues – the pandemic being one example. We build dedicated programs that respond to, evolve with, and anticipate this change.   Our platform helps activate consumers to drive healthy behavior change, by efficiently and effectively engaging them in meaningful conversations, ultimately strengthening their relationship with the healthcare organization that supports them.

Building on this expertise, mPulse Mobile has put together a COVID-19 Strategic Communications Tool Kit. It comprises a coordinated suite of programs and resources to help you purposefully connect your population to services, information and updates during this crisis and the recovery phases to follow. These include resources to mitigate adverse effects of social isolation among your population. Our COVID-19 Strategic Communications resources address varied the messaging and communications challenges of the pandemic and are based on direct experience and collaboration. To date, we’ve supported tens of millions of COVID-19 communications to patients and members via SMS, email, IVR and mobile web.