2021 CMS Changes Put Spotlight on Patient Experience

Quality performance is critical to our relationships and engagement with our collaborating health plans.  In the Medicare Advantage industry, quality is widely defined by the CMS Star measures which place Medicare Advantage health plans on grading scale from 1-5.  Plans with four or more stars earn bonus payments which allow them to invest in richer benefits which then fuels growth.  It is easy to see why the majority of our health plan agreements reflect some incentive against performance in Star measures to align our goals with those of the health plan.

Starting in 2021, the importance of Patient Experience and Access to Care on the overall STAR rating increases by 15%.  The weighting of patient experience on the overall score goes from 34% in 2020 to 40% in 2021.  This means that 40% of the overall Star score is based on survey data – driven by a patient’s perception – compared to claims-based clinical data.  CMS acknowledges this important shift in focus will be challenging for the industry – and has reported that there could be a $3.6B reduction in Medicare Advantage premiums because of the reduction in STAR ratings as a result of the new focus on patient experience.

In addition to it’s importance to the MA Star ratings, patient experience is also front and center in the quality program for the new Global Direct Contracting model for traditional Medicare beneficiaries.  In this model, 80% of the quality score is contingent upon best in class performance in patient experience.  Clearly, CMS is signaling the criticality of a patient-centered approach to senior care delivery.

In response to these developments, agilon health has recruited an experienced executive, Carol Ayangbile, who begins on December 14th to collaborate with our partners and support the development of a robust approach and playbook to patient experience.

To learn more about Medicare Star Ratings, click here.