When providers and plans collaborate on patient experience, everybody wins

Have you ever met anyone who thinks it’s easy being a patient? Getting help when you’re sick is hard work. Scheduling appointments by phone between 9–5 (with the next available appointment two months away), coordinating care between providers, and ensuring prescriptions and recommendations from Dr. Smith don’t conflict with those from Dr. Jones can make patients feel like project managers.

Despite our best efforts to help the people we serve, the suffering caused by a complex healthcare system can compound the suffering caused by illness. But the Centers for Medicare & Medicaid (CMS) is pushing payers and care delivery organizations alike to streamline the healthcare journey by increasing the importance of experience in Star Ratings. A revised system of Star Ratings was introduced in 2020 (and updated in 2023), and the changes have significant potential impacts on both plan revenue as well as the performance incentives offered to medical groups. By prioritizing the patient experience, health plans and providers can work together to make sure members get the care they need much more easily.

Medicare isn’t the only insurer focusing on patient experience measures. Medicaid and commercial plans recognize that the consumer and patient experience matter to member growth and retention. Access and experience aren’t a “nice-to-have,” but a foundational business imperative. By approaching care coordination as a “team sport”—i.e., in collaboration with health plans—medical practices can grow and earn quality bonus dollars, while (most importantly) improving care for patients.

One thing is resoundingly clear: When health plans and medical practices work together, everyone wins.

Navigating barriers to care

To more clearly understand the types of hurdles involved for patients, clinicians, and plans, consider the following example.

Mary, a 62-year-old woman, trips and hurts her foot, so she schedules a visit with her primary care provider (PCP). There, she learns she has a fracture. Given Mary’s age and medical history, her PCP considers her at risk for osteoporosis and suggests a bone density test to assess her bone health.

Mary’s PCP works with a practice that's part of a larger health system. The health system wants patients to be referred for tests internally—and Mary’s PCP nearly always does so. But when Mary schedules the appointment, she learns her co-pay will be $800. She decides to look at other options to see if the scan costs less elsewhere. And she’s surprised to learn she can get the same test for as little as $150 at a facility not affiliated with the hospital.

The logistical obstacles are numerous—and likely unknown to Mary’s PCP. For example, the clinician probably isn’t aware of the stark discrepancies in cost between facilities. They also don’t know that Mary had to take time out of her schedule to research her options, nor that the lack of transparency impacted her trust in her doctor. While health plans have a reasonable grasp of the cost issue, clinicians often don't have the deeper-level insight into those problems. What’s more, they may also face internal pressure to refer patients within their health system.

Tackling frustrations in the patient and member journey

Patients typically have good relationships with their providers. So why do more than 70% of Americans feel the healthcare system is failing them?

The answer is complicated. But the patient journey, with all its points of friction, accounts for part of the problem. The interaction between providers and patients is only one segment of that journey. Booking an appointment, scheduling follow-up tests, seeing specialists, understanding co-pays and billing, and many other factors contribute to how patients experience the entire continuum of care—as well as how high they rate their plan.

Health plans and providers must recognize that the patient experience begins well before they’re face to face with a clinician—and well beyond that interaction too. Friction at any point can have a negative impact on Star Ratings. And it can hurt the patient, the provider, and the plan.

The financial implications of Star Ratings

Let’s face facts: Making healthcare more accessible is simply the right thing to do. Outside of that, millions of dollars in quality bonus payments are also on the table, for both providers and plans where Star Ratings are concerned. For plans, good Star Ratings are necessary for financial growth. And for providers, regardless of whether a practice has a risk arrangement or a more traditional fee-for-service arrangement, experience measures and care coordination measures will impact their relationship with health plans.

Traditionally, medical practices have been focused on clinical measures, like cancer screening and diabetes care. But as incentive models evolve, capturing the most dollars possible for a medical group increasingly requires an understanding of Star Ratings, MCAHPS, and CG-CAHPS performance. Being a high performer with one plan doesn’t mean a similarly high performance with another; different plans often focus on different populations. Medicare plans by definition focus on members over age 65, while Medicaid plans focus on people with more challenging socioeconomic life circumstances. Looking at the data by plan and by line of business is necessary to develop a full understanding of performance and the changes needed to improve.

Collaboration between plans and providers is essential to ensuring the financial health of both groups, as they work toward a better patient experience. Experience ratings drive business success, and improving them is a win-win-win for plans, medical practices, and, ultimately, patients.

There's substantial financial opportunity in improving performance quickly—and Press Ganey’s strategic consulting team can help. Connect with one of our health plan experts to learn more.