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Navigating the Changing Landscape of Medicare Advantage Star Ratings in Healthcare

In the ever-evolving world of healthcare, the importance of Star Ratings cannot be overstated. These ratings, issued by the Centers for Medicare & Medicaid Services (CMS), have a significant impact on a health plan’s reputation, member enrollment, and financial performance. However, the landscape of Star Ratings is undergoing a transformation that requires health plans to adapt and implement new strategies to maintain their competitive edge. 

 Now that the 2024 Medicare Star Ratings have been released and AEP is underway, let’s delve into the recent and upcoming changes in the Star Ratings program and explore strategies and best practices to mitigate risk, overcome challenges, and improve member engagement and experience.

Want more information upcoming changes? Watch the webinar to get the full download »

Understanding the Changing Star Ratings

The 2023 Star Ratings saw a fundamental shift, with an increased emphasis on patient experience and access. The CMS introduced a weight adjustment, elevating the patient experience component from a weighting value of two to four. Even though the weighting value will move back down to 2 for 2026 stars, health plans still need to focus on delivering exceptional member experiences.

Quality ratings, particularly those related to Consumer Assessment of Healthcare Providers and Systems (CAHPS®), member experience and access, are now more critical than ever. Health plans must focus on providing positive experiences to their members to maintain high scores in this domain.

One of the most significant changes on the horizon is the introduction of the Health Equity Index (HEI), along with the removal of the Reward Factor, which was previously a vital component in Star Ratings. It’s no longer enough to provide high quality care to the general population. The HEI will require health plans to pay closer attention to the healthcare experiences of vulnerable populations, including dual eligible, low-income subsidy, and disabled individuals.

There are also some new Part D measures on the horizon around concurrent use of Opioids and Benzodiazepines, polypharmacy use of multiple anticholinergic medications in older adults, as well as polypharmacy use of multiple central nervous system active medications in older adults too. So it’s important to work with your pharmacy and clinical teams to help make sure you’re getting messaging out to providers and support to members to help manage these drug classifications. 

While the final rule changes will impact plans very differently, knowing how you will be impacted will determine your path forward. Why not apply each proposed change to your overall Stars 2023 and see the effect they have on your final results, assuming no performance change whatsoever. We’re sure you’ll find the results surprising, but more than that, it’ll arm you with the information you need to mitigate risk and adapt your strategies to ensure your continued success.

So, how can you impact and influence these measures across the Stars landscape moving forward? 

Member Experience is Paramount 

The recent changes and the introduction of the HEI emphasize the importance of member experience across the board. Now, Quality Ratings and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) ratings gauge the member’s experience and satisfaction with their healthcare providers and health plan.

Health plans should therefore view every interaction with their members as an opportunity to enhance the member experience, from appointment scheduling to care coordination. Take the time to understand not just where there’s room for improvement, but also what’s working well through the use of event-based check-ins, surveys and benefits. Implementing a three-pronged approach to behavior change that includes behavioral science, learning strategy, and a focus on health equity can help health plans drive better outcomes.

With the HEI coming into play, health plans must pay special attention to vulnerable populations. Member populations are anything but homogenous and represent a wide array of ethnic, racial and linguistic backgrounds, as well as being impacted by a variety of SDoH factors. 

NCQA started adding socioeconomic stratifications to a number measures some years ago, and this trend is expected to continue. Strategies to manage these populations should include addressing barriers to care, providing transportation options, and offering culturally sensitive content and language options to improve engagement and outcomes.

The Role of Digital Engagement 

Contrary to popular belief, Seniors, who make up a significant portion of Medicare beneficiaries, are increasingly receptive to digital channels, such as SMS messaging. While they might struggle with new digital technologies, 98% own a mobile phone (81% own a smartphone) and 94% use text messaging regularly. This shows that they are very comfortable with the simplicity and consistency of the text channel interface.

Interestingly, Seniors have some of the highest levels of engagement across population segments within programs. In fact, they have the highest levels of “conversational turns”. This means that when a plan sends a message, Seniors engage in the conversation and send responses back. Health plans should leverage these channels to connect and engage with senior members effectively. 

The Art of Conversation

There are a number of proven strategies health plans can employ to address these changes in Star ratings measures, such as leveraging best practices across behavioral science, instructional strategy and culturally sensitive and relevant content when it comes to the streaming content.

Members should feel heard, valued and informed throughout their healthcare journey. Two-way conversations are a powerful tool in this regard. These interactions, often facilitated through SMS messaging, allow health plans to engage with members effectively.

While standard two-way interactions are unable to provide tailored responses to potential barriers members might reply with, personalized two-way conversations can identify potential barriers to care or even members who may need specific screenings. Making use of Natural Language Understanding (NLU) and AI, they’re able to respond appropriately, provide real-time assistance, and enhance the member experience. In this way, health plans are able to close the intention gap and increase motivation to take action.

Furthermore, delivering culturally sensitive streaming health content that addresses health literacy gaps in a member’s preferred language can significantly impact the outcomes of outreach campaigns, improving preventive screenings and member engagement. By offering compelling, culturally relevant content, health plans can resonate more deeply with diverse populations.

The consumer experience should be at the heart of every health plan’s strategy. By leveraging best practices, like two-way conversations, personalized messaging and streaming health content, health plans can connect and resonate with their diverse member populations, and so differentiate themselves in a crowded market.

Charting a Way Forward

The changing landscape of Star Ratings requires health plans to adapt and embrace new strategies. As the industry places more emphasis on member experience, health equity, and quality ratings, health plans must prioritize these aspects to thrive in the competitive healthcare market.

By implementing behavior change methodologies, and leveraging digital engagement, health plans can not only maintain their Star Ratings but also improve the overall health and satisfaction of your members.

The Importance of Annual Wellness Visits for Providers, Payers, & Patients

Why The Annual Wellness Visit is So Important

The Annual Wellness Visit (AWV) is an incredibly effective tool for consumer health management and is key to keeping people healthy now and in the future. This valuable time spent between provider and patient gives space to check in on progress, discuss health issues, and create a care plan–not to mention it allows for the opportunity to order conduct needed screenings and preventive care, making it an easy way to close multiple gaps in care at once.

Research has shown that establishing a stronger relationship between provider and patient can positively impact health. There are also multiple indirect benefits to plans, providers, and patients, such as reduced network leakage and education on proper ER and urgent care use.

Annual Well Visit Statistics: Underutilized, Underestimated

Unfortunately, AWVs are surprisingly underutilized. Only 25% of Medicare Advantage beneficiaries receive an AWV (even though 45% of all Medicare beneficiaries have four or more chronic conditions). Many hard-to-reach populations within Medicaid and Medicare are not taking the time to schedule and attend their AWV, and many patients do not understand the importance of this visit at all.

But it is important–to both the patient and healthcare organizations. Beyond the benefit of catching and controlling health issues, the AWV is a critical component of Hierarchical Condition Category (HCC) recapturing.

In fact, an 85% AWV completion rate can result in an 80% or higher HCC recapture rate. This can mean a significant power over reimbursement dollars for plans and providers.

Learn more about improving HCC Recapturing through cutting-edge engagement strategy by watching our on-demand webinar »

Example Scenario

Our 75-year-old male patient can have two different outcomes determined by his AWV. With proper coding of his full health status in the second scenario, you see a significant increase in reimbursement–over $5,000 annually for this one patient. If you multiply that by over 500 patients, you will see an increase of $2.5 million annually (or a loss if you neglect to code correctly).

But what happens if this patient never schedules his visit or if his visit isn’t coded correctly? You’re leaving good money on the table.

Patient Demographics HCC (Hierarchical Condition Category) Risk Adjustment Factor
75-Year-Old Male   0.428
E11.41 Type 2 Diabetes mellitus w/diabetic mono neuropathy HCC18 Diabetes w/chronic complications 0.625
Total RAF   1.053
Payment Per Month   $684.45
Payment Per Year   $8,213.4

Example scenario: If this patient never schedules his visit or if his visit isn’t coded correctly. Good money is left on the table.

Patient Demographics HCC (Hierarchical Condition Category) Risk Adjustment Factor
75-Year-Old Male   0.428
E11.41 Type 2 Diabetes mellitus w/diabetic mono neuropathy HCC18 Diabetes w/chronic complications 0.625
K50.00 Crohn’s disease of small intestine w/o complications HCC35 Inflammatory bowel disease 0.279
M05.60 Rheumatoid arthritis of unspecified site w/ involvement of other organs and systems HCC40 Rheumatoid arthritis and inflammatory connective tissue disease 0.423
Total RAF   1.755
Payment Per Month   $1,140.75
Payment Per Year   $13,689
Example scenario: With proper coding of this patient’s full health status, you see a significant increase in reimbursement.

Using Technology to Unleash the Power of Annual Wellness Visits

Suppose your goal is to increase the number of members or patients you have going in for their AWV and to recapture their HCC codes properly. In that case, it’s critical to have effective outreach to educate, motivate, and drive behavior change in those hardest to reach–a challenging but attainable goal.

Behavioral Science

One of the most important tools available to increase motivation and inspire behavior change is your approach to the conversation. With behavioral science, we take what we know about human behavior and tendencies and use that knowledge to not only predict the response to our outreach but to sway people toward one action or another.

When we reach out to members and patients regarding AWVs, saying, “Hi, Susie. You’re due for your no-cost annual wellness visit,” has a measurable impact on response.

In this message, we employ the Endowment Effect, a behavioral science principle that assigns higher value to objects and tasks when consumers feel a sense of ownership and personalization. By telling Susie it’s her no-cost visit, we are making it more likely she will take action.

AI Technology

Let’s go beyond the planned messages, though. Not everything can be scripted when you start a real conversation with a real person. With Conversational AI and Natural Language Understanding (NLU), plans and providers can communicate with patients in a personalized, conversational, and real way.

Instead of one-way interactions where the healthcare organization is talking at the patient, AI and NLU broaden out your abilities into a fully-fledged two-way conversation where the patient can freely respond the way they would naturally speak, and the system can understand and carry the conversation naturally in an almost human-like manner.

If a plan is reaching out to encourage an AWV and the member says, “I don’t have a doctor,” NLU can easily recognize that response and follow up with a list of in-network doctors near the patient.

Health Equity

This technology and ability for two-way interaction opens the experience to so many more possibilities–an important one being barrier analysis.

With the ability of NLU to interpret barriers to access (such as not having access to a doctor or not having transportation to the appointment) and uncover possible social determinants of health (SDoH), the healthcare organization gains more information about the circumstances of each individual.

With AI and NLU capabilities, the healthcare organization can respond accordingly with resources, education, and support to break down the barriers tied to inequity and provide a more accessible healthcare experience.

mPulse Mobile's two-way SMS technology identifies barriers and effortlessly guides patients to schedule their Annual Wellness Visit
Revolutionizing Patient Outreach: mPulse Mobile’s two-way SMS technology identifies barriers and effortlessly guides patients to schedule their Annual Wellness Visit. Transforming care, one text at a time.

Instructional Strategy

One barrier to health equity that we often encounter is the issue of health literacy. Many health consumers need help understanding what an AWV consists of, why it’s important, or how to find a doctor to obtain one. This is where education becomes an essential part of any outreach strategy.

The video below features Dr. Archelle Georgiou, a leading physician, healthcare executive, and author, explaining why annual wellness visits are critical to preventing chronic disease and keeping a person healthy.

Including this short three-minute video can answer many questions the patient may not know they have, raise their health literacy, and increase their motivation to schedule.

Putting it All Together

These individual strategies ultimately come together to form one highly effective solution aimed at increasing the number of members and patients who schedule and attend their AWV.

mPulse Mobile’s Annual Wellness Visit solution incorporates these and can effectively drive behavior change, even among unengaged and hard-to-reach populations. With AI technology to uncover and address barriers, an omnichannel outreach method to ensure you’re reaching every member possible (no matter how hard to reach), and both behavioral science and streaming health content to inspire self-efficacy and build knowledge, healthcare organizations deploying this solution have seen up to a 61% visit rate for targeted members living near in-network clients.

mPulse Mobile's optimized patient journey ensures a seamless, informed, and empowered healthcare experience
Experience the Transformation: mPulse Mobile’s optimized patient journey ensures a seamless, informed, and empowered healthcare experience. Every step, reimagined for you.

And though this can have an impressive impact on the bottom line of healthcare organizations, it also significantly and directly impacts people’s lives and health.

The ability to catch early signs of disease and the chance to educate someone about their health and lifestyle makes the AWV one of the more powerful tools in the healthcare industry’s arsenal–so let’s make sure we are using it to its full potential.

Join 200+ leading healthcare organizations leveraging our cutting-edge solutions to improve Annual Well Visits attendance and ensure optimal health engagement through our digital health solutions. Explore how mPulse Mobile can transform AWV experiences, drive behavior change, and elevate health outcomes for your members.

2023 Star Ratings Update: Digital Engagement’s Role in Closing Diabetic Care Gaps

38% of all eligible Medicare Advantage plans saw a decrease in the Diabetes Care – Kidney Disease Monitoring measure performance from 2022 to 2023 Star Ratings. The year 2022 marks the final measurement year for this measure, with Kidney Health Evaluation for Patients with Diabetes (KED) being the proposed replacement. Acknowledging this, plans are uniquely positioned to raise performance scores and improve kidney health for diabetic members using digital health engagement solutions for condition management as they prompt their member populations and provider groups to manage a new measure.

Kidney health evaluation for patients with diabetes

The Kidney Health Evaluation for Patients with Diabetes (KED) is a newer HEDIS® measure that tracks the percentage of adults with diabetes who have been screened annually for kidney disease.

The measure includes two components:

  1. A urine albumin-to-creatinine ratio (uACR)
  2. A blood test to determine the estimated glomerular filtration rate (eGFR).

This measure is important because it can screen and diagnose kidney disease, and early detection and treatment can help prevent or slow down its progression.

Interested in closing this gap? Learn more about our Diabetic Screening Solution.

While this change intends to provide a more accurate and comprehensive assessment of a member’s kidney function, preventing downstream complications and risk, it presents a behavior change challenge for Medicare Advantage plans as improved health outcomes also support better Star Rating performance.

One way members could satisfy the previous measure requirement was via a urine test in the comfort of their own homes. Now, they will likely need to visit a lab or their healthcare provider to also complete the blood test, which can be inconvenient, time-consuming, and, sometimes, intimidating, potentially impacting member compliance and overall plan performance. Routine in-clinic lab work requires behavior change that can be nearly impossible to achieve without strategic intervention.

A multichannel engagement solution to activate diabetes patients

Using a multichannel digital engagement solution that leverages tailored conversations intentionally crafted with behavioral science to activate members is proven to empower members to overcome barriers and get tested.

Rooted in neuroscience and psychology, behavioral science uses cutting-edge techniques proven to empower and inspire members to act. As a matter of fact, a leading Medicare Advantage plan saw an 18% lift in members taking action when behavioral science was used in SMS messaging in mPulse programs versus when it was not.

Here are a few examples of behavioral science principles that mPulse incorporates into messaging to inspire member self-efficacy:

  • Social Proof: Highlighting that a member’s peers are undergoing the exam can increase the likelihood that they will schedule their appointment.
  • Loss Aversion: Highlighting the potential negative consequences of not undergoing the exam can motivate members to take action.
  • Default Bias: Making the in-person exam the default option for members can reduce the effort required to schedule the appointment and increase compliance.

Education is critical in activating and empowering members to complete a desired health action. Streaming a captivating piece of healthcare content or even a link to an existing resource can help educate members about why going in-clinic is a better way to monitor their diabetes, driving sustainable behavior change in combination with behavioral science-backed dialogue. That’s why Streaming Content and Instructional Strategy make up one of mPulse Mobile’s proprietary engagement strategy pillars.

Our team of instructional strategists and healthcare industry experts creates compelling learning experiences to close gaps in healthcare inspired by trends from consumer products and aligned with key STARS measures, like Diabetes Care – Kidney Disease Monitoring. Streaming educational health content and messaging are developed alongside thought leaders and industry experts to ensure members feel empowered, inspired, and informed to take action to improve their health and health literacy.

In fact, mPulse observed a 274% increase in retinal eye exam completions when streaming content was used in SMS versus when it was not. Powerful right? The data speaks for itself.

While the addition of a blood test to the Kidney Disease Monitoring measure presents a challenge for plans, an omnichannel digital health engagement solution utilizing behavioral science strategies and streaming content can successfully drive members to receive the necessary care, improve the overall member experience, and improve measure performance. At the end of the day, everybody wins!

Closing Gaps in Care: What Key Strategies Should Plans Consider?

$7 billion is saved annually from preventive health services, yet only 8% of Americans are attending all recommended preventive care visits. In a perfect world where all Americans received the preventive care they need, we’d be saving over $87 billion annually.

Diseases such as diabetes, cardiovascular disease, and cancer cause 7 in 10 American deaths every year and account for 75% of the nation’s health spending. It’s forecasted that by 2030 the United States will spend $6.8 trillion on healthcare annually.

Health plans are deeply familiar with the value of preventive care and continually invest time and money into programs and services that are designed to activate their members to attend important visits. Unfortunately, preventive screenings and care access plummeted throughout the pandemic and as a result, have become an even more important focus area going into 2023.

How do you solve the challenge?

Throwing money at a one-size-fits-all approach won’t move the needle. Your members are complex human beings with unique differences that require health engagement solutions that address their individual needs and preferences. Investing in a tailored gaps in care solution that helps target, identify, educate, and address each member’s barriers and preferences will yield better health outcomes at scale.

We’ve curated a checklist of key considerations that should be consulted when needing to close care gaps and achieve better health outcomes.

1. Implement a Frictionless Communication Approach 

No two members are the same and how we communicate with each member should reflect that understanding. Building solutions that leverage an omnichannel approach enables you to reach more members in the ways they prefer. A study from 2021 found 85% of members prefer receiving text message updates from their health plan and providers compared to email, phone calls, or portal messages. On top of awareness, building motivation is just as critical.

Enter Behavioral Science. Behavioral Science uses principles from neuroscience, psychology, and economics to encourage and empower members to act. By embedding these scientifically proven techniques within member communications and outreach, you’ll see improved compelling outcomes for preventive care visit completions.

Interested in seeing the impact behavioral science can have on your members? Watch the webinar series, Frictionless Healthcare, on-demand now »

Case Study: Over 5,000 New Preventative Screenings Completed

A leading Medicaid MCO partnered with mPulse Mobile to improve screening rates by enhancing previous outreach methods (mail, phone, and paid advertisements) with the addition of SMS text messaging. The program was run in both English and Spanish translation, using a combination of powerful behavioral science techniques and rewards incentives to drive members to attend needed screenings while uncovering and addressing key barriers such as transportation assistance, live agent scheduling support, and more.

As a result, 48% of targeted members completed their screenings. A prior opt-in approach enabled reach rates to exceed 80%.

2. Build Health Literacy

While creating awareness is the first step, educating members on why screenings are important, and helping them feel prepared for their visit is equally as vital. Think about it: if you don’t understand why you need to go to the doctor for something that doesn’t feel like it’s an issue, why would you spend the time and energy voluntarily going to that appointment? Providing members with educational tools designed to build knowledge and confidence will increase the likelihood that they’ll take action.

Read all about the power of education in our newly released guide, 6 Innovations in Streaming Health Content to Improve Member Experience »

Case Study: Streaming Health Education Triples Engagement

In partnership with a leading Medicare Advantage plan, mPulse Mobile launched an A/B testing program that sent messaging to members notifying them it was time to get their annual diabetic eye screening. The test group was divided in half, with group A receiving SMS messages only with a link to schedule their exam, and group B receiving the same message with a link to watch a 60-second educational video about the risks of not receiving routine diabetic eye screenings.

The results boasted a 274% increase in link clicks to schedule the eye exam when the streaming health video was used versus when it was not used.

Knowledge certainly is power. Building confidence to act using cinematic streaming experiences in undoubtably an impactful way to ignite outcomes.

3. Overcome Barriers and Create Accessibility

Factors such as income status, education level, location, access to reliable transportation, and race and ethnicity all play a significant role in accessibility to preventive care services as well as likelihood of receiving said care. Racial and ethnic minorities, particularly Hispanic and African American members, have statistically lower screening rates than white members for cervical, breast, and colorectal cancer screenings. To solve barriers for members with health disparities, you must first identify their barrier and how you can help overcome it.

By deploying multilingual omnichannel solutions, you can directly ask members what is keeping them from attending their preventive visit. Their response can determine next steps, while a customized call-to-action helps them overcome the barrier. 

Case Study: HEDIS® Measure Improvement

A Medicaid plan located in the Midwest partnered with mPulse to drive improved screening rates across multiple preventive care topics. Over 81 unique dialogs were deployed using dynamic tailoring that examined each member’s engagement rate, communication preferences, and socioeconomic data. The campaign positively impacted all targeted measures, and saw the following percentage point (pp) improvement rates:  

  • Well Child (years 0-11): +13.3pp increase 
  • Adolescent Well Care:  +9.8pp increase 
  • Dental Visit: +8.8pp increase 
  • Lead Screening: +9.5pp increase 
  • Breast Cancer Screening [BCS]: +12.6pp increase 
  • Colon Cancer Screening [CCS]: +11.5pp increase 


4. Continually Optimize Outcomes 

Because each member population is unique, the ongoing refinement of programs through data analysis and performance reviews will continually optimize outcomes. With a dedicated team of strategists, analysts, industry leaders, and both client and technology support experts, mPulse Mobile will help drive better preventive screening completions for your members 

In Summary  

As we head into 2023, plans will need to implement innovative solutions to increase preventive care visit completions. By leveraging omnichannel communication, educational tools and streaming experiences, and proactively addressing and helping members overcome barriers, we can begin empowering member action at scale. 

2023 Star Ratings: Experience Reigns Supreme as Equity Waits in the Wings

To say the events of the last two years had an unprecedented and unconventional impact on health plans would be an understatement. Fast forward from March of 2020 through the better of logic within The Extreme and Uncontrollable Circumstances Policy producing temporarily inflated 2022 Star Ratings to today. While we wait for either the end or extension of the current Public Health Emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) continues to work tirelessly to further its pledge to put patients first in all programs.

To truly put patients first, however, you have to address their needs and provide support to the plans, practitioners, and communities who care for our most vulnerable populations. Back to the traditionally timed release of the 2023 Medicare Advantage and Part D Advance Notice Part II, CMS provided plan sponsors with a sneak peek at its next sizeable agenda with an emphasis equity! This takes me back to when we first read about proposed weight increased for CAHPS® and the other member experience measures. Back when it felt nearly impossible and so much more difficult than managing numerator compliance for HEDIS® and Adherence measures. But we started taking better care of our members and alas, here we are looking at all of those 4s in the weight column of 16 separate experience measures and hoping it all shakes out in favor and balances the expected deflation in post-pandemic performance metrics.

CAHPS® and the Member Experience

CMS makes good on its promise to lend a bigger voice to the beneficiary as it proceeds with the increased weight of its member experience measures, including the Consumer Assessment of Health Plans and Systems (CAHPS®) survey. The 2022  MA-PD CAHPS survey fielding began last week and I’m sure teams are eagerly awaiting even the earliest peek at performance from their survey vendors ahead of Westat reports later this summer while the rest of us will have to wait until public data becomes available in early October. Even the best and most robust regulatory and off-cycle surveys will only represent a small percentage of members at one moment in time. Plans need more experiential and real time data around common and frequently used benefits that scales not only the entire member population, but the entire member year. mPulse Mobile has developed an event-based check-in program that not only gathers valuable member experience and sentiment data, but also has the ability to address dissatisfaction and solve common pain points in real time using its patented natural language understanding and conversational messaging.

The Extreme and Uncontrollable Circumstances Policy

As expected, The Extreme and Uncontrollable Circumstances Policy provided additional COVID-19 relief and over inflated performance numbers that will feel like a one-time get out of jail free card with the ‘better of logic’ that will not be in play for 2023 Star Ratings. This ‘better of’ method produced inflated performance numbers that will be difficult to sustain in future years. As experience continues to reign supreme, plans should prepare everyone from members to senior leadership for potential disruption and work to find ways to offset the potential loss of the one-time inflated bonus payments.

No new measures for 2023 and some moving to the display page

With no new measures for 2023 and some moving to the display page for a few years, plans will have the opportunity to continue efforts to close gaps, connect members to appropriate care, and review their data for another year. Controlling Blood Pressure makes its return to the active page with a 1x weight while Plan All Cause Readmission remains on display for one more year before returning with a 1x for 2024 Stars. Two key HOS measures, Improving or Maintaining Physical Health & Improving or Maintaining Mental Health will see their time on the display page for 2022 & 2023 as they were too disrupted by COVID-19.

HEDIS and Telehealth

HEDIS and Telehealth seem to be here to stay and work together. According to the American Journal of Managed Care, telehealth claim lines increased 3.060 percent nationally from October 2019 to October 2020. As members seek care outside of the traditional office setting, providers and payers still have a need and obligation to capture the full burden of illness and these updates include additional code sets to be allowed for measure inclusion or exclusion when captured via telehealth visits alone. This is just another example of how members, plans, and providers are embracing digital technologies. We’ll keep an eye on these flexibilities as the House recently extended virtual care flexibilities beyond the public health emergency.

Is Health Equity the new Experience?

CMS provided information on the potential development of five new equity related measures for Parts C and or D.

    • Driving Health Equity (Part C and D)
    • Stratified Reporting (Part C and D)
    • Health Equity Index (Part C and D)
    • Measure of Contract’s Assessment of Beneficiary Needs (Part C)
    • Screening and Referral to Services for Social Needs (Part C)

After two wild years of recycling data and rates due to COVID-19 to the temporarily over-inflated 2022 Part C & D Star Ratings due to the expansive extreme and uncontrollable circumstances policy, 2023 proposed changes seem to be minimal and mild in comparison. The last handful of years have had plans focusing heavily on improving their member experience with 2023 Stars rounding out the increased weights from 1.5x to 4x. Accounting for just over 50% of the plan’s overall Star Ratings weight, experience will remain top of focus for the foreseeable future. But no time to get comfortable because equity and social determinants are hot on experience’s heels with more than a handful of related measures and methodological enhancements. Proposed changes and new measure concepts must go through federal rulemaking and stabilize on the Display Page for a minimum of two years before becoming an active Star Ratings measure. mPulse Mobile has developed solutions to address and promote social determinants as well as stratify your member data within our engagement solutions to support and map to internal efforts.

It’s never too late to develop or enhance your member engagement strategy. How will you continue to wrap your arms around your members as we (hopefully) move from pandemic to endemic and beyond?

2022 Star Ratings: What We Know and What We Think We Know

To say the events of the last year had an unprecedented and unconventional impact on health plans would be an understatement. From early January 2020 when Health and Human Services (HHS) declared a Public Health Emergency (PHE) to aid the nation’s healthcare systems in responding to COVID-19 through the cancellation of the 2020 HEDIS and CAHPS collection and now with vaccines becoming vaccinations, the Centers for Medicare and Medicaid Services (CMS) has worked tirelessly to continue its pledge to put patients first in all programs.

To put patients first in all programs, you have to address their needs and provide support to the plans, practitioners, and communities who care for our most vulnerable populations. With the earlier than anticipated release of the 2022 Medicare Advantage and Part D Advance Notice Part II, CMS provided plan sponsors more time to prepare their bids during unprecedented times. While the better part of this Advance Notice focused on rate and payment policy, it provided plans with important updates and changes related to the Star Rating program which can have a tremendous impact on Quality Bonus Payments (QBP).

Following the earlier-than-anticipated Advance Notice in October 2020 came the equally early Final Rule in January 2021. Here are a few noteworthy changes that we discussed in the fall that are here to stay for 2022. For a deeper discussion, watch the 2021 Star Ratings panel with Rex Wallace, Jim Burke, and myself below.

  • CAHPS and the Member Experience. CMS is making good on its promise to lend a bigger voice to the beneficiary and will proceed with the increased weight of its member experience measures, including the Consumer Assessment of Health Plans and Systems aka CAHPS survey. While the 2021 CAHPS survey will still have a weight of 2x each (not including the flu measure) for the 2022 Star Ratings, the importance of member experience and perception is greater than ever as these measures will contribute to over 50% of the overall weight in 2023 Stars. Even the best and most robust regulatory and off-cycle surveys will only represent a small percentage of members at one moment in time. Plans need more experiential and real time data around common and frequently used benefits that scales not only the entire member population, but the entire member year. mPulse Mobile has developed an event-based check-in program that not only gathers valuable member experience and sentiment data, but also has the ability to address dissatisfaction and solve common pain points in real time using its patented natural language understanding and conversational messaging. Learn more about our CAHPS Solution.
  • Extreme and Uncontrollable Circumstances Policy was amended to note any additional COVID-19 relief under this policy for 2021 measurement year will have to come through future rule making. CMS adjusted its disaster policy and plans will be allowed to use the ‘better of’ between some of its 2021 and 2022 measure ratings. This ‘better of’ method may produce inflated performance numbers that will be difficult to sustain in future years. Plans should proactively identify their at risk areas and deploy a strategy at scale to offset a potential loss in QBP for future years.
  • With no new measures for 2022 and some remaining on the display for another year, plans will have the opportunity to continue efforts to close gaps, connect members to appropriate care, and review their data for one more year. Controlling Blood Pressure and Plan All Cause Readmissions will remain on display and likely return to the active page with a 1x weight for their first respective years. The potential introduction of a COVID-19 measure did not receive positive feedback during the open comment period and only time will tell if it was related to the reluctancy of accepting COVID-19 isn’t really going away anytime soon or the proposed collection and impact another vaccine measure may have on Stars.
  • HEDIS and Telehealth is here to stay and work together. According to the American Journal of Managed Care, telehealth claim lines increased 3.060 percent nationally from October 2019 to October 2020. As members seek care outside of the traditional office setting, providers and payers still have a need and obligation to capture the full burden of illness and these updates include additional code sets to be allowed for measure inclusion or exclusion when captured via telehealth visits alone. This is just another example of how members, plans, and providers are embracing digital technologies.
  • Part D measures, above all other measures for 2021 Star Ratings, got harder. Sure, some may think this could be attributed to CMS not having any CAHPS or HEDIS measures to use in their methodology calculations, but the increase in cut points should be attributed to an increase in performance across all of the eligible plans. Barriers to proper medication use and adherence are much greater than cost and access, especially as plans increased mail order access during the height of COVID-19. We often see poorer adherence and participation from members with the lowest cost share which tells us that what they really need is increased education and engagement. Simple one-way refill reminders for your adherence measures or offers to complete a Comprehensive Medication Review (CMR) for your Medication Therapy Management (MTM) program are no longer enough to compete with those top performing plans who are driving those cut-points higher every year. Learn more about our Medication Adherence Solution.

As shots go into arms and some semblance of normalcy begins to return, it’s still too soon to know the full impact the pandemic will have on members, plans, providers, technologies and so much more. CMS has equipped plans with a sneak peek of what’s to come and extra time to prepare for it in an effort to take better care of its members. It’s never too late to develop or enhance your member engagement strategy. How will you continue to wrap your arms around your members throughout the year and beyond COVID-19?

Key Takeaways from the 11th Annual Star Ratings Master Class

mPulse Mobile’s Government Programs Strategic Market Executive, Reva Sheehan, discussed Keeping Momentum: Best Practices to Maintain or Improve Star Ratings, with Johns Hopkins, Ph.D., Director, Quality Improvement, Tejaswita Karve, at RISE’s 11th Annual Star Ratings Master Class. Here are our Key Takeaways:

Member Experience Depends on Meeting Member Communication Preferences

Newly weighted star measures capture anything from call center measures to HOS measures and more, and all will tie back to member experience in some way. Analyzing sentiment from interactions will be an area that plans, and providers will need to focus on more heavily as those weights start to take effect. Asking such questions such as, what resonates with the member? What do members respond to? And then measuring such data and using it to meet members communication preferences, is vital to star ratings moving forward. For instance, plans will want to know which and how many members prefer IVR over text message, or email over mailers. Reva Sheehan from mPulse made an interesting point, that CMS, and others, expect plans to reach out to their members using multiple forms of communication. That means the data the plan uses to see who prefers what kind of communication should be segmented appropriately and used in addition to other touchpoints. A plan can see high engagement from email outreach, but they cannot forget or ignore the members who prefer IVR, or link-to-web. Using an omnichannel approach to execute dialogue between member, plan, and provider, is key to guiding the plan’s entire population to the right resources and messaging. Understanding what outreach works best for each member and keeping them at the center of the plan’s communication strategy will also build that trust and long-lasting relationship with their member. So, when it comes to value-based care, truly tailoring touchpoints to each member’s preference is one of the first steps to maintaining an effective and trusting ongoing dialogue.

Leveraging Communication Tools to Shift back into In-Person Care

Although star ratings will see its largest shift towards member experience, plans will still need to prioritize other HEDIS measures in addition to experience, such as preventive screenings and care for example. And plans may need to focus on those clinical quality of care measures even more so due to precautions from stay-at-home orders in 2020. With a new drop in preventive screenings alongside star ratings shifts, plans and providers have strong reasoning to leverage communication tools even more to get the message out about the importance of preventive screenings, among other health management tools and benefits. When we enter a post-pandemic phase and members start seeking out digital and in-person care, vaccine information, or following up on screenings they have postponed, providers will need to work within their systems to manage what may seem like a cascade of sudden requests. On the plan side, though it may be more difficult to directly affect what kind of care a member receives, they can help educate and set up the right expectations for the member to help ease that transition, so the member is less likely to experience an unpleasant surprise when reaching their appointment. Plans can leverage their communication tools and partners to make sure that end-to-end member experience is accounted for, which can also translate into positive CAHPS survey responses.

Scalable Solutions that Work for All

Member Engagement should encompass what works for everyone and segment that outreach accordingly to work effectively. Special populations such as hard-to-reach members and the underserved communities hold a bit of the focus in terms of member engagement, and as they should, but as the weights change over the next two years, the focus will need to widen to members that are also mildly engaged. The mildly engaged members are those who don’t need ongoing care or who have readily available access to their healthcare and don’t feel like they need to be in continued conversation with their plans. So, when it comes to scaling an engagement solution, it means using tailored content that reflects each member’s level of need. Like  Tejaswita Karve mentioned in the panel, “One method won’t work for everyone – one size does not fit all.” Understanding the nuances in the way communication formats are used is important to tailoring content to fit the member’s preferences, rather than the other way around. Capturing those preferences as useable data will give the plan an opportunity to scale their solutions more effectively than strictly going off what works for most.

Proactively Educating Members Will Continue to Make a Big Impact

Educational outreach will become even more important as we head into the vaccine phases of the pandemic. Plans and providers will also need to continue informing members about tools and benefits the plan already offers, creating more positive touchpoints and improving overall plan-member experience. For example, when the plan reaches out to members proactively, to educate them about cost savings when adjusting their medication refills, they inch closer to that triple-aim for the member and the plan. The member is more likely to adhere to their health goals and benefit from a cost saving, and the plan benefits from member adherence. Providing benefits education proactively gives the plan the opportunity to set up a positive experience for the member right from the start.

Innovation through COVID-19

COVID-19 pushed plans and providers to become more creative and innovative in the way they educate members and provide care delivery. Tools like mail order prescriptions have become more of a norm because it allows members to follow COVID safety protocols while maintaining their care. These newer habits will probably remain post-pandemic. Now that members understand how easy it can be to jump online to see their doctor, CMS quickly lifting those restrictions, and plans beginning to umbrella those costs, members are less likely to fully transition back to pre-pandemic health visit practices. Those practices often included longer wait times, requiring more resources and time from more health care workers, etc. Through all this innovation, plans, providers, and the entire industry will feel pressure to show their adaptation to changing expectations. As adoption of new virtual care platforms, digital therapies, or other tools increases, so will the need to inform members, so will the need to guide them through that adoption, and engage them to keep them connected over the long term.

As we look forward to this new year, it is a good reminder that plans should inform their members about benefits that are available to them in an ongoing, conversational manner. It establishes trust that goes beyond the higher weighted Stars measures. Ongoing communication establishes a trust that builds a long-standing relationship with members, which has proven time and time again to bear the most value for everyone.

Key Takeaways from the 6th Annual Star Ratings and Quality Assurance Summit

mPulse Mobile’s Government Programs Strategic Market Executive, Reva Sheehan, had the opportunity to discuss Member Engagement, Now and Post Pandemic, at the 6th annual Star Ratings and Quality Assurance Summit alongside Noreen Hurley, from Harvard Pilgrim Healthcare, and Bill Gaynor, from Change Healthcare on Wednesday December 2nd. During their discussion they reflected on how plans engaged their members at the early stages of the pandemic, but also what worked well and what is here to stay as we move into 2021.

The Pandemic’s Impact on Member Engagement and How It Changed Some Processes for the Better:

The pandemic highlighted many longstanding member engagement challenges and created new ones. Health plans had to think about services and resources that were impacted and how to communicate with their members as quickly as possible. An omnichannel approach was crucial in deploying messaging for many health plans that needed to reassure and inform members quickly. Information regarding COVID, CMS changes that affected members access to care, telehealth services, and impacted resources and  programs were all vital pieces of information that members welcomed and appreciated. Plans relied heavily on the communication channels and strategies they knew their members would engage with, and adapted as the situation and member engagement levels evolved. As we look forward to 2021, plans will need to continue to double down on the channels their members respond to at scale so they are able to meet the challenges of the next phase of the COVID-19 pandemic.

Using Data and Internal Agility to Adapt to Member Needs

One of the panelists Noreen Hurley, from Harvard Pilgrim Healthcare, shared how the situation at the beginning of COVID-19 forced their team to look inwardly at their own operations. “Urgency drove us to some internal coordination and to look inside our own organization and find what resources, what technology, we can use…to smash through the silos and reach as many people as we can quickly.” At mPulse, a major concern for our customers centered on getting member feedback and data quickly, to make better decisions in an evolving situation. Collecting engagement data, member responses to outreach, and analyzing member sentiment and intent all helped get actionable feedback to plans that were trying to understand how best to reach at-risk or underserved populations.

Noreen also noted that plans had to constantly monitor their engagment efforts and change strategies quickly. In mPulse’s case, we had deployed our COVID Rapid Rollout toolkit but still had to adapt as programs launched as stay-at-home orders extended beyond the original three-week timeline. We also experienced a higher need for social isolation education solutions which addressed the need to stay active, as well as resources for easily accessible healthcare options. mPulse deployed several solutions to address what we thought would be the need for COVID-19 related challenges and needed to pivot quickly when some solutions become more important than others.

Member Engagement Will Become Personal

A number of factors are converging to shift member communications further away from a one-size-fits-all strategy for Medicare plans. The emphasis on CAHPS as part of Stars going forward means that every member touchpoint, no matter how transactional, needs to be assessed through the lens of member experience.  Just as there is no copy-and-paste solution for gaps in care or med adherence, plans will have to think about what will work best for their specific member population when it comes to experience-focused engagement. No matter what population you’re looking at, personalizing content to make it relevant and useful to the individual member is always important. Technology is helping plans to pull in real-time data on experiences and sentiment and member interactions with providers, pharmacies, member services, etc and build a better picture of what their happy and dissatisfied members look like. This allows them to tailor content and align resources where they can make the most potential impact.

Placing members in context is vital in ways that go beyond CAHPS scores. For example, even with the newly added accessibility to telehealth, many members still faced language and technology resource barriers that made it nearly ineffective for hard-to-reach members to manage their care virtually. A generic “sign up for our telehealth portal” email or text message would have resulted in frustration or inaction for those members. So gathering those barriers up front via conversational outreach, and tailoring follow-up with education and support resources to help overcome them was crucial for many of mPulse’s clients’ telehealth success in 2020.

A Vaccine and 2021 is Right Around the Corner. What will Plans do Differently to Improve Member Engagement?

Aside from OEP and the more-normal member engagement strategy that plans will be rolling out next month, plans face the challenges of vaccine communication and navigating another Stars Measurement Year that will be impacted by the pandemic.

A vaccine will take time to distribute to the general public and the lines will be long when it gets here. Plans will need to focus on continuing education around the fallout of the pandemic, vaccine distributions, and what regulatory changes will mean to member’s health management. Educating members swiftly and timely must remain a permanent change within the industry. Using data and insights about what worked and what did not during 2020 will become necessary when planning future communications. So will having tools readily available to collect new data and adapt as the vaccination effort continues. Plans need to show members that their health plan is listening, concerned with keeping them healthy, and ready to address whatever the new year presents.

One key strategy we’ve seen throughout COVID-related outreach is the success of quick, actionable touchpoints with members, supported by richer educational materials when necessary. mPulse is already adopting this strategy for communication about vaccines and the FAQs that will be vital to driving vaccine uptake in large populations. We use data and member responses to tailor content to different personas – from “ready and willing” members who just need to know when and where to go get vaccinated, to “unsure and uneasy” members who need more information from authority figures and richer content to help drive them to act. We think this approach is vital, as polls continue to show a very divided population when it comes to attitudes around the vaccine heading into January.

CAHPS: How to Plan for 4x Weighted Stars Measures 

Earlier this month, we noted that October is the month for Medicare advantage in our discussion of the 2021 CMS Star Ratings release. Last week saw the other major Medicare Advantage event of the month, with the start of the Annual Election Period. As plans enter the member acquisition and retention season and all efforts are focused on maximizing plan growth, they hope to finish 2020 in a strong position ahead of OEP and to start 2021 with more returning and new members.  

 That period of time, when plans traditionally begin onboarding new members and welcoming returning ones, will be more important this year than ever before.The reason why is simple: the impression new members get of your plan, and the validation (or lack thereof) that returning members feel about their decision to stay, will now impact a lot more than retention. The 2021 CAHPS survey for Medicare will feed into Stars measures that are 4x weighted for the first time ever, and those Member Experience measures will comprise the largest component of plans’ overall ratings.  

Returning members, who are receiving marketing materials and outreach right now, will be responding to questions as soon as February 1st 2021 on the CAHPS survey. Those questions cover 6-month periods. This means member experiences occurring right now may impact these high-weight measures for the 2021 survey and 2023 Stars. 

From Campaigns to Relationships 

All plans understand new member onboarding and returning member outreach is crucial during the months of AEP and OEP. But the changes coming in 2021 mean following the traditional playbook this year could hurt performance, as members receive high touchpoints and support from October to January, only to have the cadence of plan communication go “back to normal” just before CAHPS surveys begin to be fielded. Viewing enrollment, retention, and onboarding as discrete “campaigns” misses the opportunity to see this time period as the beginning (or new chapter) of a relationship between the plan and member.  

That relationship must be nurtured and supported all year to maximize member satisfaction and experience, not just these traditionally-important months.  

 mPulse helps many of our Medicare partners with new member onboarding and navigation, but our plan experience solution also supports ongoing, year-round touchpoints and conversations to continually connect members with relevant benefits, resources and tools to keep the member connected to their plan, and maintain that relationshipWhether you work with us or not, this year-round approach is increasingly becoming the standard for MA plans as member experience and orientation becomes a priority for quality teams as much as it is for member services, marketing, and retention departments.  

Connecting with members about their benefits year-round is one part of the relationship-based approach to member experience. But like any relationship, it has to be a two-way street. That means plans must find ways to listen more to members and help them feel heard. Many have already started, going beyond grievance/complaint tracking and proxy CAHPs surveys to create more conversations with their members.  

Several MA plans we work with use automated check-ins – sometimes related to an event like a provider encounter or a customer service call, sometimes just because they haven’t heard from the member in a while  where they can get the pulse of large populations. With strong Natural Language Understanding and response handling, they can hear common questions and concerns then serve up relevant resources and tools – connecting a member who waited on hold with a call scheduling tool, for instance. And asking for feedback at scale on conversational channels means that member feedback can be analyzed for sentiment, intent, or keyword to help make more informed and member-centric decisions.  

The changes to the CAHPS measure weights mean that every member touchpoint, or lack thereof, is now a key opportunity for Quality Improvement as the relationship between members and plans takes a central role in performance. Your strategies and communication plan for member onboarding is likely finalized. But now is the time to think about “what’s next?” to continually strengthen that relationship and keep members engaged with their plan throughout the CAHPS season and beyond.  

Want to learn more about how we can help? Check out our CAHPS Solution.

2021 Medicare Star Ratings: What it Means for Member Engagement

The wait is over! Today 400 Medicare Advantage and 55 Part D plans received the final 2021 Star Ratings from the Centers for Medicare and Medicaid Services (CMS). This is always a milestone day for every Medicare organization. Plans who perform well receive higher quality bonus payments and rebates, and have been shown to outperform lower-rated competitors in member acquisition and retention.  

This is also a big day for mPulse as we look at the role of member experience and engagement in determining a majority of each plan’s summary rating. Even in this year’s release where CAHPS and HEDIS data is carried over from the 2020 ratings, we see how CMS changes and increasing Part D competition make a major impact on performance. So, as our team looks at the 2021 data, we are always looking at the implications for the dozens of Medicare plans we partner with and member engagement overall. 

Here are some themes that stand out to us: 

Mostly Neutral and Negative Movement for Plans 

The Medicare quality landscape got even more competitive this year, continuing a trend we’ve seen from CMS in recent years to push for more stratification between plans in ratings. While the number of 5-star plans increased by one, the overall number of plans at or above 4 stars declined by a net of 16. While the 2020 ratings saw an impressive 52% of contracts at or over 4, this year’s group will drop to 49% of MA-PD contracts. With many data sources remaining static, a lot of the negative movement plans experience will be due to cut point shifts, weighting updates, and the measures that weren’t impacted by COVID-19 changes.  

This year’s data aside, the number that jumps out the most at us today is 212. That’s the number of MA-PD contracts appearing as “too new to be measured” this time, compared with the 400 actually measured. Established plans have to prepare for these newer contracts to pursue higher ratings with intense focus, knowing that a poor start can be difficult to recover from.  

mPulse is working with both long-standing plans that are evolving their quality strategy to protect high rating, as well as newer contracts that want to compete with highrated plans immediately. The common theme we’ve heard from both types of teams is that they know they need to do more than the standard quality improvement playbook. They’re going beyond traditional engagement channels and provider-relations-centric approaches, using partners like mPulse to differentiate member experience and activate each of their members. Today’s news will only accelerate those trends.  

CAHPS Weighting Adjustments Have an Impact 

Member experience is a major topic in Medicare and these 2021 ratings are a reminder of why. This year was supposed to be a transitional period where non-flu CAHPS measures move from 1.5x to 2x weight before eventually moving to 4x in 2022 and 2023 ratings (the measurement year of 2021, coincidentally). But since CAHPS data was carried over from last year’s ratings due to COVID, plans are in the unexpected situation of seeing the same data impact their overall rating more, with good being better and bad being worse.  

While many plans will be frustrated to see CAHPS improvement efforts not reflected today, the work they have done and strategies they put in place now will have a huge impact soon. Plans that have relied on meeting call center requirements and fielding proxy CAHPS surveys are moving towards dedicated CAHPS/HOS strategies and member engagement solutions focused on Member Experience. As we see what a 25% increase in measure weight looks like today, plans are thinking about how they can understand and improve member satisfaction next year, where the weight will increase by another 100%.  

We’re working with our partner plans to create new, conversational touchpoints with members and feed critical experience data back to the entire organization – helping them make decisions driven toward improving CAHPS and HOS scores before the next major weight jump.  

Medication Adherence Is Even More Competitive 

As expected, the measures least impacted by the COVID changes were the ones to experience the most cut point movement. These measures represent an important area of focus for plans heading into next year. The Medication Adherence measures were at the top of this list with their traditionally narrow cut points and triple weighting. These measures saw a uniform drop in average MA-PD rating of .1 to .2 stars, and the SUPD measure, 3x weighted for the first time, dropped .4 stars on average. Plans that did well in these Part D measures will be very pleased today since they faced strong headwinds this year.  

Medication Adherence is one of the key measure sets for plans that work with mPulse since so much of success depends on member action. It’s another area where intense plan competition is only going to increase as more plans look to improve adherence in their entire populations and go beyond simple refill reminders. Connecting members to initiatives like 90-day supplies and mail order pharmacy, as well as gathering data on barriers to adherence helps plans improve their measures and make better decisions about pharmacy quality strategy.  

Understanding why an individual member isn’t adherent helps us get the right resource to them immediately via mobile channels while helping build a better understanding of what we need to do to help the entire population improve. That sort of understanding is critical as plans look to deal with ever-higher cut points and even more competitors going forward.  

The 2021 ratings are going to be remembered for all of the unusual circumstances impacting them. But for all of the carried-over data, impending weight shifts, and large number of new contracts, we think they tell a consistent story. Medicare Advantage plans will continue to succeed in large part by how well they engage their members to deliver a differentiated experience and drive vital actions to improve their health. We join our MA-PD customers in looking forward to a more “normal” 2022 rating set, and are excited to deliver solutions to help them reach their organizational goals, create innovative experiences for members, and ultimately better serve the people they care for.