ACA’s Quality Rating System – An opportunity to gain market share

Starting in 2015 all issuers of Qualified Health Plans (QHPs) on the Healthcare Marketplace will need to provide Quality Rating System (QRS) measurements that will be aggregated and scored to provide consumers with a star rating for each product offered.

How many stars will you have?

Although there are still details to be worked out by CMS, the required measures for the 2015 beta test are in place. All issuers that wish to continue providing QHPs on the Marketplace will need to provide the required measures. There are two different sets of measures included in the beta specifications.

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The first is a set of clinical quality measurements that are mostly taken from the current NCQA HEDIS accreditation process. Many issuers already collect the data for these measures; especially, if they are meeting the requirement to be accredited for the Marketplace today and are using NCQA for that process.

The second is set of measures derived from an enrollee satisfaction survey (ESS) that needs to be performed by an accredited third party survey vendor. Most of the questions in the ESS are drawn from CAHPS. The survey processes requires that a sample of data is drawn, audited by a third party and provided to the survey vendor. The vendor then performs the survey and reports the results to CMS. Questions focus on rating an enrollee’s satisfaction with a plan over a six month period.

While the QRS initiative driven by the ACA attempts to provide transparency, it also creates a competitive market that will force issuers to look at ways to increase the quality of care and enrollee satisfaction to deliver better scores. The prize? For consumers, better products. For issuers, a larger share of the market.

Want to participate and win? Then you need a solution that not only provides the required measures, but also provides insight and the ability to drive quality improvements. This can be accomplished with a well thought out solution architecture that provides processes for delivering the measures and the means for analyzing data to drive improvements.