What Makes the 4.5- and 5-Star Rated High Performing Plans Different?

April 18, 2022 Editor

Every health plan wants to perform well for its members, of course, but it’s just a select crop of plans that can prove it with 4.5- or 5-Star Ratings from CMS and NCQA. And it’s just not the larger resource-rich national plans that can pull off these high ratings, many smaller regional and state-centered plans have also proven capable of reaching the heights of excellent performance. 

Foundations of High Performing Healthcare Organizations

The critical issues of excellence in healthcare organizations, according to the American College of Healthcare Executives (amusingly acronymed ACHE), are:

  • Emphasizing the mission and vision
  • Understanding and meeting the needs of all stakeholders
  • Building a culture that listens, empowers, trains, and rewards
  • Measuring performance, seeking benchmarks, and continuously improving
  • Protecting the corporate capability

Most every health plan strives for all the above to some extent, though the pathways to many of those goals, as you know, can be fraught with twists and turns. Realizing what the obstructions are to reaching some level of achievement on these five foundations might be an important foundation in and of itself. 

What the high performing plans do that others don’t

5 Stars for Medicare Star Ratings

Looking at the landscape of 4.5-5.0 rated plans, particularly during this most recent pandemic-driven year, gives us a comprehensive and enlightening perspective of how those plans have strategically positioned themselves to generate such desirable ratings. 

Finding those plans wasn’t too difficult. Practically all of them already partner with SPH Analytics for their member experience and engagement solutions. More than 94% of NCQA’s 4.5-5 rated and 100% of their 5-rated Medicare and commercial plans as well as 96% of Medicare Advantage and Part D plans with CMS 4.5-5 Star Ratings are all SPH clients.  And they are showing some common threads: 

Adam Higman, Partner, Strategic Consulting, Press Ganey: “4.5- or 5-star rated plans are less measure-by-measure driven, and more member-centric. Those higher performing plans look at their performance through a more holistic lens by driving the enterprise and culture to be more member-friendly, reducing hassles for the member, looking at healthcare from the member’s perspective and not as much about how we ‘improve this or that measure.’ Continuing to be more innovative while continuing to differentiate their plan from its competitors. It’s their mindset that’s a little different as to how they approach the member experience.”

Mike Foytik, Chief Analytics Officer, SPH Analytics, a Press Ganey Solution: “The higher performing plans just have more of an interest and a focus in digging into the data beyond just the standard CAHPS reporting. Doing more mock surveys, more oversampling. They ask for additional reporting, more drill-down, more data-digging appending additional sampled fields to the results. From us (SPH), they get predictive modeling on the back-end to try and estimate which members are likely becoming dissatisfied with the plan or to disenroll, and try to proactively address those. Casting out a broader net, not just targeting a few things but truly looking for every insight and adding it as a cumulative effect rather than just focusing on one measure. It’s the broad picture they’re after, and they use data to help guide their focus.”

Suzanne Cogan, General Manager, Payer Solutions, SPH Analytics, a Press Ganey Solution: “Those are also the plans that go beyond typical standard time frames for provider access.  So, they might have in their contracts with their providers a relatively tight time frame by which the provider has to see a new patient or an established patient.” 

Take your place among the high performers

Member experience is now taking up more real estate than ever in the Star Rating calculations. By being informed with key insights into the healthcare experience of your members, particularly with descriptive and predictive analytics from SPH (incorporating pivotal historical, comparative, and even predictive perspectives), your plan can improve your member experience and engagement to join the other top performers in the health plan market.

Enjoy a free and timely webinar about the upcoming changes to Star Ratings calculations which weigh CAHPS measures more heavily. With member experience and access measures making up 57 percent by measurement year 2023, MA plans will need to consider Star Ratings and member experience in nearly every aspect of their organizations. You can view the webinar here.


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