Capturing the Member’s Voice: Shifting CAHPS Measures Can Shift Stars

As CMS accelerates the shift towards experience-driven Stars measures, improving CAHPS has become one of the largest controllable drivers of Medicare Advantage revenue, retention and competitive advantage. Some industry analysts suggest that experience measures will comprise nearly 40% of Stars performance by 2029.

CAHPS captures where member experience falls short in real life, bringing meaningful impacts to both revenue and member retention. Last minute interventions don’t solve the perceptions members have built over time. Retrospective chart chasing is no longer an option as measures become electronic. And, there is no way to tell which members will be surveyed.

Improvement in these experience measures demands cross-functional alignment across service lines and consistent communication. The same message for all members will no longer get you there, and member personas often lack the unique situation of the “person.” AI-generated content is not yet mature, and the associated regulatory concerns make customized approaches challenging for marketing and legal departments.

For Medicare Advantage plans facing CAHPS-driven Stars risk, MedOrion provides a measurable, scalable path from reactive management to measure level execution. This case study explores how one plan achieved CAHPS measure improvement.

Sinking Stars

2023 was an inflection point for one national health plan. Having lost their 5-star rating, they knew that CAHPS, especially Getting Needed Care and Care Coordination had driven the decline, but it was hard to know how to reverse it. “PCP Informed about Specialist Care was one of their consistently lowest performing items,” recalls Dave Burianek, Chief Strategy Officer at MedOrion. “The health plans own internal Stars Predictive Model predicted at best they would do 3.5 stars for MY2023.”

Beginning with a 150,000 member pilot for their HMO population, MedOrion came with a strategy that seems simple, but can be incredibly complex to execute, they would need to address all measures for all members.

CAHPS Measure Improvement

CAHPS measures are difficult to address because there is no way to pro-actively identify who receives a survey. To create a meaningful lift, they would need to impact a broad population, not just those at risk for low scores. To move the needle on Stars, improving CAHPS meant targeting all members to address complaints before they happen, with a strategy anchored in three truths:

• Each measure needs to be treated uniquely.
• Each member needs to be treated uniquely.
• Create the least member abrasion possible.

The Decision Logic

MedOrion’s approach is to tackle the measure itself, with member engagement as a natural output of that strategy.

“Predictive analytics is baked into all member engagement programs, including ours. But, the solution needs to go beyond just predicting who might do what. For CAHPS, we go beyond just trying to identify who is most likely to score low, to figure why they will score low, which we refer to as a ‘situational indicator.’ And, then the potential barrier to closing that gap, which is something we refer to as a ‘behavioral indicator.’ The interventions are then tailored accordingly, and we’re continually monitoring those members and can quickly identify when something has changed and we need to intervene again,” says Shai Levi, Chief Product Officer at MedOrion.

The Clinical Indicator

First, the program needs to identify what clinical profile members will have within the measure. For Getting Needed Care, for example, some members will have a chronic condition and need to see a specialist. Some members will be healthy, but need preventative screening. The way those members are approached will be different.

The Situational Indicator

The next layer is understanding what the circumstances are within that clinical profile. Does the member need a specialist because they are newly diagnosed? Are they presenting with multiple conditions? Do they need a preventive screening but have a new diagnosis? Are they recently out of active treatment and don’t know they need to go back to regular screening?

The Behavioral Indicator

After identifying both the clinical and situational indicators of any measure, the program needs to tackle the behavioral profiles of a member. Is the member overwhelmed with a recent diagnosis? Are they feeling fine and don’t thing they need screening? Are they struggling to get transportation to appointments?

These inputs, overlayed with embedded Stars measure logic, create a unique outreach strategy for each member based on a series of approved plan messages and channels.

Every Measure, Every Member, Every Time

Since low satisfaction in areas like benefits communication and access to care negatively impact CAHPS, success means first tackling complaints before they happen. The start of the program was simple, begin outreach to all members digitally using signal equations to determine the best message and method. With the decision logic in place, members would receive personally relevant messaging. And an increased focus would be placed on those most likely to complain. For that population, the engagement would also include a phone call.

Focus on Complaints

The call center reached out to individuals most likely to complain to ask about their current experience with the plan using an anticipated barrier model. 50% of those contacted complained about not fully understanding their benefit design. The remaining half struggled with a combination of scheduling appointments, getting the correct tests and treatments or scheduling transportation. A smaller subset had unrelated complaints that are were not addressed on the CAHPS survey.

Armed with that information, MedOrion created a decision model targeting members on unique aspects of Getting Needed Care, with the test group performing better than control on “access to services,” “logistics, “quality – plan services” and “quality service provider.”

Early Indicators

The plan saw a 5% improvement in mock survey rates, with a 15% reduction in overall complaints. By September 2024, the plan saw a 2% improvement in GQC for the test group and a 5% improvement in GNC. The control groups, in contrast, saw less than 1% improvement in both measures. Specialist visits from May – August exceeded the control group every month.

By the end of MY2023, the plan had moved two-stars per measure (2024 CAHPS season), and achieved an overall 4-star rating for MY2023 beating their predicted expectations, which they maintained in MY2024.

Going All In

In 2025, the plan decided it was time to apply the success of the pilot to their entire membership. Leveraging MedOrion’s unique measure framework, real-time data refreshes, early indicators and AI-assisted prioritization, they began individualized outreach tied to claims, diagnoses and behavioral cues.

Early Results

To determine year-over-year lift, the original test group was followed continuously through 2025, as the program was rolled out to everyone. That subset saw additional increases in care coordination, improving an additional .4%, double the prior year. The previous control group now on the program improved by .7%.

Both groups also improved in Getting Needed Care with the previous control group improving .6% and the original test group improving more than double with a 1.4% increase.

How We Can Help

As member journeys become more clinically complex, getting members to do what you need them to do isn’t just about identifying gaps and moving members to take action. Member engagement success today requires coordination across quality, experience and operations teams that is strongly anchored in organizational priorities and clinical outcomes. The need for high-level coordination also requires a different level of partnership.

We understand the challenges of today’s Medicare Advantage market and can help improve your measure scores and overall Star rating, one member at a time.