3 Steps One Medicaid MCO Took to Boost Its Patient Experience Score

Focus on a population

It seems counterintuitive for a plan to narrow its focus to serve all of its members more efficiently, but this approach was vital for Aetna Better Health of Kentucky’s success in patient experience.

Mankovich and her team identified two disease states that affected most of the payer’s membership: diabetes and hypertension. They poured much of their attention and efforts into making routine processes faster and easier for members with these conditions.

Kentucky ranks fifth in the US for the highest prevalence of adult diabetes and sixth nationally for hypertension or high blood pressure. Over 13 percent of the Kentucky population reported having diabetes, and almost 40 percent reported having hypertension.

“Just being really focused on specific disease states that are prevalent in our state, we knew it would impact large cohorts of our membership, and I think that that's apparent…in the score and what we achieved with these rankings,” Mankovich said.

Aetna Better Health of Kentucky aimed to improve HbA1c screenings, improve diabetes eye exam rates, complete routine blood pressure checks, and other chronic disease prevention and management tasks for members with diabetes and hypertension. By ensuring that these tasks were easy and quick to accomplish, the payer improved care speed and ease overall.

Understand member motivations

The challenges and opportunities that affected member experience often differed from member to member. For some, lack of transportation might mean they never make it to their appointments on time or at all. For others, they need an incentive to prioritize their HbA1c checkups.

First, Mankovich and her team had to determine their members’ motivations. What drove members to engage with the healthcare system? What barriers stood in the way of or encumbered engagement?

To answer these questions, the payer delved into its Consumer Assessment for Health Providers and Systems (CAHPS) responses.

This survey is approved by the CAHPS Consortium under the Agency for Healthcare Research and Quality (AHRQ). The surveys evaluate large patient populations using standardized questions and data collection methods. The questions aim to give stakeholders a better grasp of the patient experience.

CMS has 14 CAHPS surveys spanning different providers, including outpatient and ambulatory surgery, fee-for-service providers, home health, and others.

Each year, after conducting a CAHPS survey, Mankovich and her team thoroughly assess the results to understand how their Medicaid beneficiaries experienced access to care in their plan.

“We develop a comprehensive strategy annually following the results of that survey to ensure that we are adjusting and reacting and responding to that feedback,” Mankovich explained.

Second, the payer engaged frontline workers to understand the barriers that might impact certain regions or communities.

“We’re talking with community-based organizations that are on the front lines working with our members on a regular basis to help them eliminate any social determinant of health barriers they might be seeing,” Mankovich shared.

“We know that some social determinants of health (SDOH) needs might be more specific in various regions of the state. They might not be the exact same statewide. And so…talking to members and providers and community-based organizations throughout the state to see what actually is causing a barrier or what is important to a member to ensure that we are helping them get to their physician and get the care that they need.”

Align with provider, regulator access to care efforts

In addition to understanding members’ motivations, aligning the payer’s access to care efforts with providers’ and state regulators’ endeavors was key.

Providers hold the key to treatment. They are the ones that members are seeking to access. So, the health insurer tried to identify and remove any administrative barriers that might block members from connecting with physicians.

For other payers, this effort could take various forms, depending on the Medicaid plan’s policies, the provider partners, and the members’ needs.

For instance, there are two significant barriers to care that health insurers need to address, according to the American Hospital Association (AHA): prior authorizations and delays or denials for reimbursement. Medicaid managed care had the second-highest inpatient prior authorization initial denial rate (15.5 percent) compared to other types of coverage.

There has been a movement to standardize prior authorizations to streamline this system and to adopt electronic prior authorizations. Payers responded positively to a proposed rule promoting electronic prior authorization processes.

However, Aetna Better Health of Kentucky and payers like it represent the fact that health plans must rely on more than macro-level changes to solve access to care barriers. They have to take the initiative to identify and root out the issues in their own systems, together with their provider partners.

By improving processes for certain patient populations, listening to members’ motivations, and aligning with other stakeholder efforts, the Medicaid plan was able to boost its star rating and, more importantly, the ease and speed with which members could access care.