The Impact of Member Experience and Access Measures on Medicare Star Ratings

The Medicare Star rating program is integral to how Medicare Advantage plans receive payment and grow their membership. The Centers for Medicare and Medicaid Services (CMS) have designed the Star program to be heavily influenced by member experience, according to Blue Cross Blue Shield of North Carolina’s Karen Coderre, PharmD, BCPP, director, pharmacy clinical and quality programs, and Madhavi Manduru-Rao, PharmD, manager, pharmacy quality programs. In their presentation at AMCP 2021, the two executives summarized changes in how CMS altered Star rating weights for member experience in the 2021-2022 calendar years and commented on its potential impact on health plans.

The presenters pointed out that the Stars program helps determine overall plan reimbursement, including quality bonus payments from CMS. Plans are only eligible for quality bonus payments if they receive at least a rating of 4 stars (out of a possible five). Bonuses increase for ratings of 4.5 or 5 stars.

“In 2021, 77% of all Medicare Advantage enrollees were in plans with a rating of four stars or higher,” they said. The average star rating for all Medicare Advantage plans in 2021 was 4.06 stars.

Much of the member experience information used by CMS is derived from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) dataset. Member experience data are collected for three reasons, said Drs. Coderre and Manduru-Rao: to support consumers in making informed choices among Medicare health and prescription drug plans, to identify opportunities to improve services and quality of care, and to measure the quality of care from the beneficiary’s perspective.

In May 2020, CMS issued a final rule that doubled the weight of the member experience and access measure (from 2 to 4) for the 2021 reporting year. The presenters said that member experience now comprises 32% of the total star rating. The rating now includes:

  • Getting needed care.
  • Getting appointments and care quickly.
  • Customer service.
  • Care coordination.
  • Rating of health plan.
  • Rating of drug plan.
  • Getting needed prescription drugs.

The CAHPS survey, they noted, includes several pharmacy-related questions. These involve whether health professionals or drug plan personnel contacted the member to ensure they filled or refilled prescriptions, whether the member could not afford to fill a prescription, and the ease of obtaining medicines prescribed by the doctor. Other questions refer to counseling about the medications by the doctor or pharmacy.

The presenters confirmed that member experience has been affected by the COVID-19 pandemic, evidenced by office closures, delayed home drug delivery, lack of transportation options, and even drug shortages. To compensate, many health plans have offered greater access to telehealth services, permitted early medication refills, and waived cost sharing for specific therapies.

They added that health plans need to take a multidisciplinary approach to member experience, with a focus on ready exchange of data to identify care gaps and targeted education to provider groups and case managers. Internal plan stakeholders (i.e., customer service, case managers, and sales team) will need to be part of the process to minimize member abrasion and complaints.

Manduru-Rao M, Coderre K. The Role of Member Experience and Access Measures in Star Ratings. Presentation B10. Presented at AMCP 2021; April 12-16, 2021.