CHAP Q: How often did the provider seem informed and up-to-date about the care you received from other providers?

In recent years, the United States has experienced a significant decline in the number of healthcare providers, with a projected shortage of up to 139,000 physicians by 2033, according to the Association of American Medical Colleges (AAMC). This shortage has had a direct impact on Medicare Advantage (MA) plans, which have faced significant challenges in building and managing provider networks. The impact of this trend has been particularly dire for MA plans, as they strive to offer quality healthcare to their members.

The decline in the number of healthcare providers has made it difficult for MA plans to meet the Centers for Medicare & Medicaid Services (CMS) network adequacy standards. According to the National Association of Insurance Commissioners (NAIC), "Network adequacy requirements ensure that enrollees have timely access to covered services from a sufficient number of in-network primary care and specialty physicians." This requirement has become increasingly challenging for MA plans, which must ensure that their members have access to a wide range of services, including primary care, specialist care, and hospital care.

The shortage of physicians and other healthcare providers has a direct impact on the quality of care that MA plans can offer. The Medical Group Management Association (MGMA) reported that 43% of healthcare providers experienced burnout in 2020, which can impact the ability of MA plans to enroll new members or retain existing ones. Providers experiencing burnout may be less likely to provide quality care, leading to reduced member satisfaction and lower CMS ratings.

CMS evaluates the satisfaction of providers through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the Community Health Accreditation Program (CHAP) survey. The CHAP survey is a voluntary accreditation process for home and community-based healthcare providers, designed to assess the quality of care provided by these entities. CMS uses the results of these surveys to evaluate different STAR ratings categories for MA plans. The STAR rating system is an important factor in determining the reimbursement rates that MA plans receive from CMS.

A hypothetical example of a CHAP survey and member experience with an in-network provider could be as follows:

1. How often did the provider explain things in a way that was easy to understand?
2. Example: The member was referred to an in-network specialist for a specific procedure, and the specialist provided detailed information about the procedure, including risks, benefits, and expected outcomes.
3. How often did the provider listen carefully to you?
4. Example: The member visited their primary care physician with a concern, and the physician listened carefully to their symptoms and concerns before making a diagnosis.
5. How often did the provider show respect for what you had to say?
6. Example: The member was discussing a treatment plan with their physician, and the physician listened to the member's preferences and concerns before making a final decision.
7. How often did the provider spend enough time with you?
8. Example: The member had a complex medical issue that required a longer visit with their specialist, and the specialist spent enough time with the member to fully understand the issue and provide an appropriate treatment plan.
9. How often did the provider seem informed and up-to-date about the care you received from other providers?
10. Example: The member had received care from multiple providers for a specific issue, and their specialist was aware of the care they had received from other providers and integrated this information into their treatment plan.

In conclusion, the shortage of healthcare providers in the US is a significant challenge that has dire consequences for the healthcare industry, including Medicare Advantage plans. MA plans have faced significant challenges in building and managing provider networks due to the shortage of physicians, which has impacted the quality of care they can offer to their members. CMS evaluates provider satisfaction through surveys, which impacts different STAR ratings categories. Provider burnout due to the shortage can impact MA plans' ability to enroll new or retain existing members.

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