In addition to managing health plans for attractive, competitive benefits and solid member retention, health plans need to account for the quality ratings produced by CMS' Star Rating System for Medicare Advantage and DHHS' Quality Rating System (QRS) for ACA plans.
Member Insight is a Twin-edged Blade.
A quality rating study is a special type of member experience study whose primary objective is to link member experiences to their overall ratings of health plan performance. These studies ask key questions from quality rating questionnaires (the CAHPS survey for Medicare plans and the Quality Rating System survey for ACA plans) and then delve deeper to capture information about the experiences that are associated with the questionnaire responses. In short, such a study uses one or more of the global quality rating measures -- for example, overall health plan rating or overall health care rating -- as a proxy for the member experience portion of a Star Rating or QRS score, and then measures how strongly these global ratings are affected by member experiences. Below are examples of findings that have supported health plan decisions about managing member experience.
| Report Topics | Examples of Results | Health Plan Response |
| General Results | Communication issues are a top driver of the Overall Health Plan Rating. Communication problems were related to cost increases and network limitations. | Health plan began using more email and text for direct communication and social media for general messages. |
| Care Coordination | When doctors did not "always" talk to members about prescriptions, health plan ratings were worse. Similarly, when test results were later than expected and doctors failed to follow up with them, ratings were worse. | Health plan identified members most likely to be confused or disappointed by pharmacy and lab services and developed special out bound communications to set expectations and assure they were met. |
| Customer Service | Members gave the health plan low ratings when they felt the help understanding coverage was unsatisfactory. | Health plan created supplemental materials and messages to support traditional Explanations of Benefits and call center operators. |
| Drug Coverage | Surprises in out-of-pocket costs for prescriptions drove the overall rating down. | A formal process for communication of changes in formulary was developed and implemented. |
A New Generation of Research.
While identifying and acting on areas of health plan operations that destroy member loyalty and satisfaction has been valuable to management, a new generation of quality rating study is emerging in which the negatives are not the only focus -- sources of positive member experiences are also captured and reported. In the view of leading managers, the research can be leveraged to understand what is creating member loyalty and satisfaction.
This approach is, in part, a response to the growing complexity of a highly digitized environment. Telemedicine, member portals, smart phone apps, and personal medical devices create opportunities for great leaps in service and quality of care, but also the risk of making bad investments. For health plans, understanding how members are using all channels of service and what is generating positive service outcomes is helpful input for upcoming investment decisions.
Another reason that the "creating loyalty" approach is developing is that the expectations have increased for health plans to manage population health and use social determinants of health to generate greater population benefits. Studies can be designed to measure the link between people's circumstances and the creation of loyalty.
A new quality rating diagnostic study might have the following areas of investigation:
- Quality Rating Questions that include satisfaction, health plan rating, likelihood to renew, willingness to recommend (NPS).
- Areas of Member Experience to measure components of member experience such as Customer Service, onboarding, cost/coverage issues, etc. This is key information for creating driver analyses predicting quality ratings.
- Access to Care. Not all barriers to health can be identified through internal data. And certainly not most instances of loyalty and satisfaction creation. Diagnostic surveys capture unmet health needs and barriers to care and can help management learn what can be done to create a better information and decision environment for members.
- Health Outcomes/Utilization identifying the social determinants of health that are precursors to ER visits, inpatient admissions, and ambulance rides as well as the uses of alternatives to these high cost services.
Learn More.
Deft Research has a well developed process that ensures the reliability of research, but each quality rating diagnostic study is custom-built to answer the needs of specific clients. To discuss the possibilities, please complete the form below and one of our executives be in touch.