The Centers for Medicare and Medicaid Services (CMS) issued a notice with comment yesterday, officially scheduled to be published in the Federal Registrar on November 19th, describing the overall Quality Rating System (QRS) framework for rating Qualified Health Plans (QHPs) offered through an Exchange. CMS is soliciting comments on the list of proposed QRS quality measures that QHP issuers would be required to collect and report, the hierarchical structure of the measure sets, and the elements of the QRS rating methodology.
CMS states that the QRS framework is built around QHP ratings based on health care quality and outcomes, consumer experience, and cost. CMS sets forth its framework for “creating, implementing, maintaining, and revising the QRS” in the notice. The framework consists of two components, “Performance Information” and “Rating Methodology,” which CMS breaks down in detail.
The Performance Information component is the focus of the notice. Performance Information is broken down into four subcategories, including “Measures Selection,” the list of proposed QRS quality measures that QHP issuers would be required to collect and report. Measures selection and measure set evaluation criteria were developed using the National Quality Forum (NQF) Measure Evaluation Criteria. CMS seeks comments on the 42 proposed QRS measure sets for QHPs offered to adult individuals and families, as well as 25 proposed QRS measures for child-only QHPs (Child QRS). For example, “Breast Cancer Screening” is listed in the general QRS measure set, while “Follow-Up Care for Children Prescribed ADHD Medication” is listed in the Child-Only QRS. The full proposed measure sets table begins on page 15.
In addition to the measure sets, CMS seeks comments on the hierarchical structures for the QRS and Child-Only QRS in order for consumers to “easily use information from the QRS in their health plan comparisons for selection of a QHP in the Exchange.” The QRS organizes measures into sets of QRS Domains that represent “unique and important aspects of quality,” as seen in Table 3 on page 20 of the notice. These Domains are broadly categorized in three summary indicators, including (1) Clinical Quality Management, (2) Member Experience, and (3) Plan Efficiency, Affordability, and Management. The summary indicators would be broken down further for a “Global Rating Scale”: one score that summarizes all measures, composites, and domains in the QRS hierarchical structure.
The second component of the notice, the QRS Rating Methodology, aims to define how QHPs will be scored and compared in a meaningful way. CMS proposes several Rating Methodology components, broadly categorized as Measure Scoring Rules, Aggregation Rules, and Reference Standards. CMS seeks comments on “ways to ensure the integrity of QRS ratings.”
Finally, CMS solicits comments on identifying priority areas for future QRS measure enhancement and development. CMS provides some hope of clarity down the road: “In future rulemaking, we intend to propose requirements for QHPs and Exchanges regarding the collection and submission of specific quality-related information. In addition, we intend to provide future technical guidance for QHP issuers and Exchanges related to the QRS measure specifications, detailed rating methodology guidelines, and data reporting and procedures.” In the Future Considerations section, CMS promises to “continually monitor the QRS and make necessary adjustments to ensure that the methodology and measures remain consistent with the intended goals and principles of the QRS.”
CMS also states that as the “enrollment in QHPs expands,” they will consider “reporting the QRS at more granular levels.” CMS also notes that it will consider developing a QRS that would be “applicable to other Exchange offerings, such as stand-alone dental plans, catastrophic plans and health care saving accounts.”
There is a convergence being seen in all parts of the healthcare system from insurance companies to hospitals to healthcare providers that quality care and meeting quality measures are important for all participants to achieve.
Comments on the notice are due by 5pm ET within 60 days of publication in the Federal Register, putting the deadline around the week of January 13, 2014.