Last month I posted “ACA’s Quality Rating System – An opportunity to gain market share”, which explained how QHP issuers can gain market share in the individual space. In that blog I mentioned that, as part of the Quality Rating System, plans offered on the Marketplace will receive a “Star” rating based on a 5 star rating system. Over the next few 
posts, I would like to take a look at what this means from a health plan’s perspective.
As background, there are 43 measures that will need to be tracked. Out of the 43 measures, 31 are derived from data and 12 are derived from the survey. In addition, the draft QRS scoring specifications published by CMS organizes the 43 required measures into composites that roll up into eight domains. These domains are as follows:
- Clinical Effectiveness
- Patient Safety
- Care Coordination
- Prevention
- Access
- Doctor and Care
- Efficiency and Affordability
- Plan Services
The eight domains are then rolled up in to three summary indicators: 1) Clinical Quality Management; 2) Member Experience; and 3) Plan Efficiency, Affordability and Management. And of course, the final result is a star rating.
The most important unknown at this time is the calculations and weighting that will be used when creating the composites, domains, summary indicators and final star rating. This will ultimately affect which areas a plan will need to focus on the most; however, there are some areas to look at while waiting for the final scoring rules.
The two main areas to focus on when evaluating where a plan might rank are current NCQA HEDIS Accreditation rankings and current CAHPS scores. Why? Because almost all of the QRS data measures are existing NCQA HEDIS measures, and almost all of the Enrollee Satisfaction Survey questions are taken from existing CAHPS surveys.
Of course there are a couple of items one must keep in mind when looking at current HEDIS Accreditation and CAHPS scores: 1) the plans being measured; 2) the population being used for reporting; and 3) the differences in measurement scoring for health plans that chose another accreditation entity such as URAC for HEDIS Accreditation.
In the next couple of posts I will outline some factors to consider for both the data and survey measurement requirements.
