Star Ratings and Member Experience: Two Sides of the Same Coin

For health insurance payers, achieving success in Medicare Advantage (MA) hinges on the Stars. Higher Star Ratings not only drive enrollment and retention (with 74% of MA-PD members currently enrolled in contracts boasting 4-stars or higher) but also contribute to increased revenues through bigger bonuses and rebates (with an expected increase in bonus payments totaling $13.8 billion in MY2024). The challenge? Maintaining high Star Ratings or improving upon existing ratings gets increasingly difficult over time.

Every year, alterations to the Star Ratings methodology introduce a fresh round of adjustments for Medicare Advantage plans to navigate. 2024 was no different. CMS made significant changes, including revising cut point calculations using the Tukey Outlier method, among others. Subsequently, only 31 MA plans attained a 5-Star Rating and the average rating declined from 4.14 to 4.04  –  a major cause for concern as competition intensifies in the MA marketplace. 

But it’s not all bad news. Even as the Star Ratings system changes in sync with the evolving healthcare landscape, MA plans can improve their ratings by elevating member satisfaction. 

Why member experience matters now more than ever

Heavily weighted CAHPS measures continue to influence Star Ratings year after year. They prioritize member experience by assessing the health plan’s customer service capabilities as well as ease of accessing care promptly and when needed. Additionally, CMS’s latest revisions to the Star Ratings system in the 2023 Final Rule emphasize member experience even more. The revisions aim to prioritize health equity and address social determinants of health (SDOH) by introducing a new Health Equity Index (HEI). The index is designed to incentivize plans that serve and achieve better outcomes among larger low-income, dual-eligible, and disabled populations. For plans, effectively reaching these cohorts will be key to success.

While the HEI incentives are set to impact Star Ratings starting in 2027, the calculations will be based on health plan data between 2024 and 2026. This means plans must begin to devise strategies now, in 2024, focusing on the identification of care gaps and implementation of proactive engagement efforts.

Major roadblocks to elevating the member experience

The reality is achieving a superior member experience is a challenging journey fraught with obstacles. MA plans often face resource and capability constraints as they strive to meet CMS compliance requirements while simultaneously enhancing member engagement and satisfaction. Two other factors pose significant challenges:

• Overemphasis on compliance: While plans understandably prioritize compliance to maintain operational integrity and avoid contract termination, the intense focus on compliance can inadvertently result in a tunnel vision approach – placing extensive guardrails, diluting customer experience, and negatively impacting the member experience – consequently lowering their Star Rating.
• Outdated engagement strategies: Failure to effectively listen to their members and address essential elements of member experience and care delivery also leads to less-than-ideal outcomes for plans. Lack of personalization, limited communication channels, reactive support strategies, and disjointed experiences – all hamper meaningful interaction, leading to disengagement, dissatisfaction, and potential disenrollment on the part of members.

Getting member experience right: 4 strategies

Here are four strategies aimed at maintaining a sharp focus on closing care gaps while simultaneously adopting a proactive approach to increase benefit utilization, driving enhanced trust, member satisfaction, and loyalty.

• Enable data-driven identification of care gaps: Utilize advanced data analytics to identify care gaps – such as missed preventive screenings, medication adherence issues, or gaps in chronic disease management – and tailor interventions. Incorporating Social Determinants of Health (SDOH) data into predictive models can be a game-changer in improving member engagement and communication effectiveness. Answering questions such as, “Does the member have access to transportation?”, “What does their support system look like?”, and “Are they financially stable?”, can help you better identify care gaps, and design more personalized and impactful campaigns. 
• Drive holistic engagement across the member journey: Engage and support members across their health journey to deliver a seamless and positive experience while promoting better health outcomes. This involves helping members understand the enrollment process and their benefits, promoting preventive care and wellness, and providing care coordination for members with chronic conditions. Harness advanced data analytics to segment your members based on their health conditions, risk factors, and utilization patterns, to prioritize outreach efforts. Direct these calls to trained and specialized advocates who possess empathetic techniques and disease-specific knowledge to optimize utilization and effectiveness.
• Utilize AI for advocate empowerment: Healthcare advocates often spend inordinately large amounts of time navigating multiple systems to gather the right information to best support each member. Deploy AI-driven knowledge bases to push the right information to your advocates at the right time, not only making their lives easier, but also improving efficiency and tailoring experiences. Providing advocates with real-time customer insights, alerts, benefits information, and personalized recommendations enables them to gain a better understanding of your members’ current and future needs, swiftly address issues, and proactively suggest optimal solutions.
• Enable scalable recruitment automation: Deploy AI algorithms to quickly analyze large volumes of applicant data, including resumes, application forms, and assessments, and identify top candidates based on predefined criteria such as skills, qualifications, and cultural fit. By leveraging adaptive learning techniques, AI can also dynamically adjust training content and delivery methods to suit the unique needs and preferences of each learner, leading to more effective learning outcomes. Tailoring training programs to the specific needs of each employee enables rapid mastery of job-related skills and knowledge, ultimately leading to improved key performance indicators (KPIs) such as Customer Satisfaction (CSAT), Average Handling Time (AHT), and attrition rates.

Start early for a successful year’s end

In an election year, where healthcare affordability and access take center stage, it’s even more important for MA plans to intensify their focus on member experience early in the year. Prioritizing member experience now, versus mid-year, can go a long way in ensuring numerous strategic, financial, and operational benefits. From ensuring election advertising does not negatively impact Annual Enrollment/Open Enrollment (AE/OE) strategies and timelines to driving member satisfaction and improving Star Ratings. 

By 2030, nearly half of the MA-eligible population is projected to be aged 75 or older, compared to roughly 40 percent currently. A crucial question is: will MA plans be able to rapidly adapt to the changing Stars methodology to drive member and plan success? Those plans that integrate digital technologies like AI, automation, and analytics with empathetic human skills, adaptable workforce strategies, and seamless omnichannel engagement will take the lead in the industry.

Photo credit: marchmeena29, Getty Images