Key Takeaways

In December 2022, the Centers for Medicare and Medicaid Services (CMS) announced 41% of what goes into a five-star rating will be based on member experience starting in 2024. Although CMS scaled the metric back slightly from its 2020 proposed rule, input from enrollees will remain critical to payors.

That’s why digital health has emerged as a useful tool for payors to get ahead of the curve and foster positive experiences for the members they serve. And with billions of dollars at stake, it’s crucial to understand how Star Ratings work and how healthtech can help.

How has reimbursement to payors changed in the past decade?

The passing of the Affordable Care Act (ACA) ushered in sweeping changes to how healthcare is structured, delivered, and paid for. This included establishing a quality bonus program (QPB) that increased payments to Medicare Advantage plans based on performance. 

Encouraging payors to compete more for enrollees with quality benchmarks, CMS rates health plans on a five-star scale to decide if they should receive a payment bonus, as well as the difference between the estimated maximum federal payout versus the payor’s predicted spending. 

What are Medicare Star Ratings? 

How much payors get paid depends on various factors. CMS leans on a robust Star Ratings system to track health plan performance and quality — and how much money to pay out.

This is where member experience is so crucial. Running from 1-5 stars, the Star Ratings system weighs several factors to assign Medicare Advantage plans an overall ranking:

It’s important to note that Star Ratings aren’t just used by CMS to land on reimbursement amounts. They’re also public-facing on Care Compare, which means individuals review and read about different health plans when they select their health plan coverage. 

With health plan ratings declining in customer service over the past two years, simplifying and improving member experience for beneficiaries isn’t optional. It’s something every participating health plan should be laser-focused on so that they don’t leave money on the table — in the short- and long-term.   

How can digital healthcare help payors boost Star Ratings?

So how does digital health come into play? Forward-thinking innovations offer payors concrete tools for enhancing care management and closing gaps in member experience. Intelligent care enablement — scalable technology that supports both patients and care managers — is particularly well-positioned to help insurers in their efforts to uphold key quality standards.

Since CMS announced it will weigh member experience 2x more when calculating health plan Star Ratings, adopting and leveraging intelligent care enablement platforms helps:

1. Improve care navigation

Even with advancing technology, people experience friction when navigating care. Members encounter roadblocks at multiple stages, including when seeking care providers, scheduling appointments, and finding transportation. Leading healthcare platforms like Memora Health go beyond simple text appointment reminders to guide members throughout their care journeys with education resources and check-ins — and escalate issues that require additional support to the care team to provide hands-on navigation assistance.

2. Remove barriers to healthcare

Digital health can help expand healthcare access and improve health equity. It's often difficult for patients to reach their care team or their health plan over the phone, and SMS is an easier method of communication — with more immediate responses than playing phone tag. Health inequity continues to challenge the industry and affects the member experience. But with data showing individuals across all ages use SMS, technology that leverages AI and natural language processing (NLP) to intelligently engage members through text helps payors connect with more members where they are, when they need care.

3. Level up the member experience

Member experience is influenced by more than what happens at the doctor’s office or in the hospital. It’s impacted by interactions with payors and while getting support to find the right provider. Digital health enables care managers to reach more members at every touchpoint — before, during, and after care — by saving valuable time through automation of routine and administrative tasks.

4. Improve quality performance in real time

With the right digital health platform, you don’t need to wait until CMS publishes Star Ratings to know where you stand. Leverage automated member check-ins, identify gaps in care, gauge social determinants of health, and automate preventive care reminders to ensure your members are satisfied well before they report their experiences.

CMS Star Ratings continue to evolve. But member experience will always play a critical role. Digital health platforms provide opportunities to not only meet members where they are and enhance their overall experience, but also provide a scalable way for your teams to make care more accessible and always-on. 

Learn more about improving member experience with digital health.