CMS gears up for major quality performance program overhaul for ACA program

The Centers for Medicare & Medicaid Services’ (CMS’) recent issuance of the 2017 Letter to Issuers in the Federally-facilitated Marketplaces and Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule affirms the agency’s plans to elevate the importance and transparency of quality performance by Qualified Health Plans (QHPs). Despite the continued absence of financial incentives for high-quality QHP performance, CMS’ approach to quality oversight for QHPs is looking much like the early years of the Star Ratings program within Medicare Advantage (MA).

Similar to the MA Star Ratings program, CMS will use a 5-star scale to assign a Quality Rating System (QRS) rating to each QHP based on validated clinical measurements and enrollee survey responses. This year marks the first year QHPs must display these quality ratings prominently to consumers on their websites during the open enrollment period. Public reporting of these clinical measurements and enrollee survey responses will not only offer both consumers and providers new insight into a QHP’s clinical quality performance but will also spotlight the consumer’s perception of the QHP’s operations.

The Affordable Care Act requires QHPs to submit a Quality Improvement Strategy (QIS) for the 2017 plan year if they offered coverage through the Marketplace in 2014 and 2015 and meet certain additional criteria. CMS requirements for the QIS, which must be submitted during 2016 and implemented no later than January 2017, include implementation of:

• A payment structure that provides increased reimbursement or other incentives to providers or enrollees to improve quality and reduce costs by incentivizing high-value rather than volume-driven care, and
• 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;
  • Wellness and health promotion activities; and/or
  • Activities to reduce health and healthcare disparities.

Because strong quality performance is necessary for long-term viability, QHP leaders will likely set new quality-related performance goals and evaluate whether current operations may need to be adjusted to meet those goals. Achieving such goals amidst the ongoing industry evolution, within the competitive environment, and within budgetary constraints will require innovation and creativity. Fortunately, many QHPs can lean into their own organization’s Star Ratings experiences, expertise, and successes to help with these efforts.

An increased focus on quality, enrollee experience, and outcomes within a QHP will likely require new, short-term resource investments. Investments may be needed in areas such as population health management tools and analytics; member outreach, support, and education; and provider education, support, and engagement. By collaborating with their MA colleagues, QHP leaders may be able to leverage and expand MA tools, tactics, and expertise to simultaneously avoid the “learning curve,” minimize provider abrasion, and optimize outcomes through such investments. With careful planning and strategic deployment of resources, a QHP can leverage its short-term investments for long-term return on investment.

Whether your organization is developing a QIS for your QHP, seeking insight to help align your QIS with successful Star Ratings strategies and tactics, or needs help interpreting the quality data recently provided by CMS, we can help. For additional questions and inquiries about how Gorman Health Group can support your QHP quality programs, please contact me directly at msmith@ghgadvisors.com.

Resources

For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year’s information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn’t. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>

.