Current state of CMS quality rating programs

For Marketplace plans, quality is coming to the forefront as Quality Rating System (QRS) and Quality Improvement Strategy (QIS) requirements are rolled out for Qualified Health Plans (QHPs) starting in 2017. In short, pending the approval of proposed regulations,the following changes are coming for 2017:

  • CMS will be publicly displaying QHP quality rating information on;2
  • QHP issuers will be allowed to include 2016 QRS and QHP Enrollee Survey results in marketing materials;
  • QHP issuers must adhere to guidelines, including the QRS Technical Guidance and User Guide for the 2017 Coverage Year, established by Federal Department of Health and Human Services in consultation with health care quality experts and stakeholders.3
  • QHP issuers will be required to implement a Quality Improvement Strategy (QIS), described as a payment structure that provides increased reimbursement or other market-based incentives for improving health outcomes of plan enrollees.
    • The QIS must include at least one of the following:
      • Activities for improving health outcomes;
      • Activities to prevent hospital readmissions;
      • Activities to improve patient safety and reduce medical errors;
      • Activities for wellness and health promotion; and
      • Activities to reduce health and health care disparities.
  • QHP issuers must report on progress implementing the QIS to the applicable Marketplace on a periodic basis.

The attempt to evaluate the quality of not only health plans, but also health care providers has been in the works for quite some time within the Center for Medicare & Medicaid Services (CMS). Transparency efforts have emerged as a path to building a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people. Toward those ends and using the common theme of star ratings, CMS has already built a suite of tools for consumers to access and review information detailing the quality of the providers as well as options for facilities prior to seeking care. Armed with this information, consumers can be selective and savvy health care shoppers, especially when making important life decisions like what nursing homes or hospitals they will utilize for planned treatment or stays. Imparting knowledge about these quality and transparency tools (even simple reminders that the tools are available to consumers), is an effective way for regulators and agencies to assist consumers and health policy advocates.

CMS recently released the first ever home health patient experience ratings. These measures, known as the Home Health Compare Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey, provide information on the quality of care Medicare-certified agencies provide to patients. This publically available survey data joins a growing list of transparency efforts spearheaded by CMS aimed towards increasing consumer transparency and access to quality health care.

Likewise, Nursing Home Compare features an overall star rating for each nursing home.

These compliment and expand on other rating tools.  Although this isn’t new information, it’s a good reminder of what we can offer consumers to encourage educated, proactive health care choices.

  • Physician Compare uses star ratings to display ratings for several meaningful measures for group practices.
  • Dialysis Compare uses star ratings to help make data on dialysis centers easier to understand and use.
  • Hospital Compare uses star ratings to help consumers compare and choose among hospitals.

As we anxiously await the QRS for Marketplace plans – the ability to offer Marketplace patient experience information and the introduction of quality measures to evaluate QHPs before purchase – we should not lose sight of these tools we currently have at our disposal. States will need to take stock of the existing quality measurements and requirements as they plan for the next wave of Federal quality developments.

More information about the QIS is available here.

More information about the QRS is available here.



2   CMS anticipates issuing technical guidance annually that will detail requirements for QRS and QHP Enrollee Survey.


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