Key Steps to Prepare for the Quality Rating System (QRS) 2016 Rollout

January 7, 2015 Inovalon

The beta launch of the Centers for Medicare and Medicaid Services’ (CMS) Quality Rating System (QRS) will begin early 2015 in preparation for a full rollout in January 2016. Although reporting is required for beta testing in 2015, the QHP’s quality ratings are not publicly available until 2016. As such, there are quite a few steps health plans must take in order to prepare for the rollout, which are outlined in detail below.

What

QRS will inform consumer selection of Qualified Health Plans (QHPs) offered through a Health Insurance Marketplace, facilitate regulatory oversight of QHPs, and provide actionable information to QHPs for performance improvement.

Who

Any QHP issuer offering family and/or adult-only coverage of any category though the marketplaces that offered coverage during the previous benefit year and meets the minimum enrollment criteria (greater than 500 enrollees).

When

From January 2015 to June 2015, QHPs will calculate QRS measures and have data validated. In June, QHPs will submit QRS Clinical Measure Scores to CMS via the National Committee for Quality Assurance (NCQA). During the summer, CMS will calculate QHP’s QRS scores, providing those scores in the fall of 2015.

How

There are *43 QRS measures. Thirty are clinical measures that encompass clinical effectiveness, prevention, access and efficiency. Thirteen are QHP enrollee survey measures. The measures are organized into eight domains: clinical effectiveness, patient safety, care coordination, prevention, access, doctor and care, efficiency and affordability, and plan services. The domains are grouped into three summary indicators that are used to produce a global rating: clinical quality management, member experience, and plan efficiency and management.

Why

Improving CMS QRS scores not only results in better clinical and quality outcomes, utilization and financial performance, it also offers health plans the opportunity to differentiate from competitors to achieve a superior value-proposition among other comparable health plans participating in the Health Insurance Marketplace.

Action Steps

Having someone in your organization who can champion this effort during the beta stage in preparation for the 2016 launch is a key first step. This person will need to form a cross-functional team with respect to the following:

  1. What specific CMS deadlines will we need to meet between now and Jan. 1, 2016?
  2. What accreditation and state-based marketplace requirements, if any, do we need to be aware of?
  3. Which portions of this project will be performed in-house and which will be outsourced?
  4. Who will be our data validator?
  5. Who will be our survey vendor?
  6. What data-governance tools might we need to use as we prepare to submit our measures?
  7. What role will member engagement and provider engagement play in our scores?
  8. What role will predictive analytics play in our scores?

Although Health Insurance Marketplaces are not required to publicly display the beta-quality-rating information on their website, CMS says it will be releasing display guidelines in time for required public display in the fall of 2016. Clearly, health plans that begin preparations during the beta launch period will be better prepared to take full advantage of scoring opportunities during the final rollout.

* 29 of the 43 measures are required for reporting during the 2015 beta test.
The remaining 15 measures require at least two years of coverage data in order to report, and CMS intends to require these measures as part of the 2016 QRS measure set. CMS will publish a final 2016 QRS measure set after the 2015 beta test. Also, some state-based marketplaces or accreditation bodies may have additional reporting requirements.

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