The Medicare Advantage market shows no signs of cooling over the past two decades. As the number of plans offered continues to grow, competition for members and retention will continue to intensify. Traditionally, Medicare Advantage plans compete on two variables: price and coverage. However, the majority of plans now charge a $0 premium, effectively eliminating cost as a competitive angle. And since most plans offer additional benefits—from dental and vision services to transportation—Medicare Advantage plans will have to shift the basis of competition from cost and coverage to the member experience.
This transformation was long overdue. Consumers are demanding more of an on-demand, technology-driven, personalized member experience on their terms and in their own home, in part because they’re getting that type of experience from every other consumer-facing industry. Think Amazon Prime, DoorDash, Netflix. Healthcare, which remains largely a drive, park and wait industry, is the last holdout. Recent studies found that seniors over age 65 expect their plan to provide a more personalized health care and aging experience.
As Medicare Advantage plans find ways to meet rising consumer expectations, the Centers for Medicare and Medicaid Services (CMS) is also raising the bar by making member experience and satisfaction the driving force behind Star Ratings.
At the beginning of 2023 member experience metrics will quadruple its value, determining 57 percent of the total star rating. Eight of these measures are determined by Consumer Assessment of Health Care Providers and Systems (CAHPS) survey questions, many of which are not designed to capture consumer sentiment about health plans.
Medicare Advantage plans must prepare to enter uncharted territory—or risk losing their competitive edge in a saturated market. Success will require a renewed focus on profoundly improving overall health care. This starts with strengthening the front door of health care: primary care.
The renewed role of primary care
Although most of the CAHPS measures exist outside the scope of Medicare Advantage plans, they fit right into the realm of primary care and support members as they navigate health care and benefits. Over the past decade, non-traditional healthcare providers have entered the primary care market to expand access to convenient services while facilitating a more personalized healthcare experience. These primary care models will be critical partners for Medicare Advantage plans in 2023 and beyond.
If the member experience is the new basis of competition for Medicare Advantage plans, these models hold the keys to success. Here’s how advanced primary care models will help Medicare Advantage plans succeed in CMS’ newly weighted CAHPS measures.
Winning user experience
In order for members to get the care they need, Medicare Advantage plans must understand their members and anticipate their care needs. Medicare Advantage plans can score high on “Getting the Care You Need” measures by offering primary care services that build trust and foster deep relationships with their members. Taking a whole-person view opens the door for Medicare Advantage plans to personalize the health care experience and ensure members get the care they need, when they need it.
Medicare Advantage plans may sweat over the idea of taking a hit in star ratings for their members who wait months to see a specialist or spend half an hour in their primary care provider’s lobby, but the increased burden of measures under “Get of Care Fast’ category provides an opportunity to expand the toolbox and greater integration of care delivery. The most durable advanced primary care models will offer hybrid care that reaches members wherever they are – including virtually and at home, with high availability. It will be critical to maintain an omnichannel provider network where members can engage with their providers when and where they need care—online, over the phone, in the neighborhood, and at home.
Members’ opinions regarding their experience with the health system are now a much more weighted measure in CMS star ratings through Enrollee Ratings measures. Advanced primary care models increasingly focus on improving quality and reducing costs through value-based care arrangements. These models offer plan flexibility, and providers must not only improve quality, but also compete with member experiences. They provide services that address social determinants of health, enable more frequent contact with health services, and create a constant flow of useful information for the care team and the member’s health plan.
Measures in the How Well Doctors Communicate category will also be more heavily weighted beginning in 2023, and Medicare Advantage plans’ ability to facilitate seamless care across the health continuum will be reflected in their star ratings. Innovative primary care providers are uniquely positioned to meet this need. Primary care models that do this well will help members navigate the complexities of their health care journey by asking questions, organizing services, and leading coordination between specialists and other care teams.
Medicare Advantage has long been a market where innovation thrives—where new models and approaches are embraced, experimented with, and expanded into commercial plans. With the rise of member experience measures in Star Ratings, CMS is signaling a broader transformation in the role payers can and should play in the care delivery system. Medicare Advantage plans can respond to the moment by making highly accessible and personalized experiences the new standard of care, starting with new models of primary care available on demand virtually and in the home.
Photo: Mykyta Dolmatov, Getty Images