The U.S. health insurance industry has changed drastically over the last 20 years. Payers increasingly focus on demonstrating the value of their offerings under pressures from increasing consumer awareness of plan differences, growth of value-based care programs, and government regulations like the Affordable Care Act’s medical loss ratio. Competitive pressures and complex regulatory plan performance reporting requirements create an additional challenge – acquiring correct and accurate data to demonstrate the best possible value to potential members, governmental agencies, and employer purchasers.

This value is calculated by analyzing data that reflects the members’ experience and satisfaction, the quality and effectiveness of care, and costs to the payers and members. Organizations like Centers for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) use this data to create “scores” that reflect the value of different health plans to potential members, governmental agencies, and the employers buying/who buy health insurance. In general, these metrics cover several areas including patient satisfaction, clinical outcomes, and the quality of care provided. Calculations require the collection and analysis of disparate data sets such as Electronic Health Record (EHR) clinical data, claims data, and Consumer Assessment of Healthcare Providers & Systems survey data.

Reported data calculations and weighted final scores ultimately help potential members and employers determine the quality of plan offerings and inform critical plan and provider payments.

How HEDIS^® scores and Star Ratings help consumers

Two major organizations have developed widely accepted plan performance measurement and reporting standards. The NCQA formed in 1990 to accredit managed care plans. A year later it released the Healthcare Effectiveness Data and Information Set (HEDIS^®)¹ scores as a tool to measure and communicate plan performance across six domains of care:

• Effectiveness
• Access/Availability
• Experience
• Utilization and risk adjust utilization
• Health plan descriptive information
• Electronic clinical data systems measures

In 2007, CMS instituted the Medicare Star Rating system to help inform the public about Medicare Advantage and Medicare Part D plan quality. These ratings are calculated with several data sets, including HEDIS^®, and cover:

• Wellness/maintaining health
• Chronic disease management
• Member experience
• Member complaints
• Customer service
• Drug plan performance

These two programs provide employers and consumers with the information they need to objectively compare healthcare quality and outcome measures. According to the NCQA, the number of Americans enrolled in health plans that report quality results using HEDIS^® has grown to more than 200 million, or about 60% of the U.S. population. More than 62 million people are currently enrolled in Medicare, which reports Star Ratings.

Health insurers prioritize improving HEDIS^® scores and Star Ratings because lower ratings can put millions of dollars of reimbursements and payments at risk. An accurate and complete representation of member populations, and accurate and complete reporting of clinical outcomes, can mean the difference between one star and a half-a-star in the rating system — scores that have a very real impact on CMS payments and a plan’s reputation.

How data curation helps payers

The Verinovum whitepaper, Enabling Compliance: high-quality data provides the foundation for improved care and quality measurement, discusses the repercussions of using substandard data to determine a plan’s quality and performance ratings.

The whitepaper outlines the advantages of working with partners to transform your clinical data into a clean, accurate, and actionable asset that can be leveraged to improve clinical outcomes, enhance the patient experience, reduce costs, improve operational efficiencies, and ensure that the data used to calculate HEDIS^® and Star Ratings is accurate and complete.

Download the whitepaper here.

¹HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).