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How Quality Measures, Star Ratings Impact Healthcare Payers
High performance on standardized quality measures like HEDIS and Medicare Advantage Star Ratings help consumers determine how to choose between healthcare payers.
Quality performance metrics such as HEDIS, Medicare Advantage Star Ratings, and standardized core quality measures can give consumers an indication of healthcare payer quality.
Standardized quality measures the quality of care and coverage a payer provides based on the regularity of services performed, improvements in patient health, and consumer satisfaction.
Commercial, Medicaid, and Medicare payers can leverage quality metrics to market their health plans as ideal insurance options for beneficiaries.
HEDIS, Medicare Advantage Star Ratings, and CQMs measure similar healthcare services and consumer-facing operations, but some quality datasets are more specialized and include metrics such as consumer satisfaction rates or chronic disease screening activities.
HEDIS
The Healthcare Effectiveness Data and Information Set (HEDIS) is an extensive set of measures used to assess healthcare utilization and determine how services impact beneficiaries’ health outcomes.
HEDIS measures are maintained by the National Committee for Quality Assurance (NCQA) and cover a wide range of healthcare services.
More than 90 percent of health plans in the US use HEDIS to measure performance. The measures allow stakeholders to compare health plans based on quality. In addition, the measures can help health plans identify their own areas that need improvement.
Over 190 million people are enrolled in plans that report quality results using HEDIS, according to the Department of Health and Human Services (HHS).
HEDIS measures span six domains: effectiveness of care, access and availability of care, experience of care, utilization and risk-adjusted utilization, health plan descriptive information, and measures reported using electronic clinical data systems.
Payers collect HEDIS measures to report the number of chronic disease screenings providers administer to patients and to monitor healthcare utilization rates, follow-up appointments for medical and behavioral conditions, and supplemental healthcare evaluations.
HEDIS measures can be highly granular with detailed reporting requirements and are updated yearly by NCQA.
In 2018, the measures were updated to include data on adolescent vaccination doses, medication-assisted treatments for opioid and alcohol dependence, and a new measure for Medicaid plans that identifies the cause of hospital readmissions.
Health equity is a growing concern in healthcare, prompting NCQA to update the 2023 HEDIS measures to include race and ethnicity data and gender-relevant care measures. NCQA added race and ethnicity stratifications to eight HEDIS measures to address care gaps and health inequities in health plan performance.
Measures that reference pregnancies were also updated to remove the limitation to women.
“This change acknowledges that pregnancy and childbirth are not experienced exclusively by individuals who identify as women and will reduce the likelihood that transgender members are inadvertently excluded or inappropriately included in a measure due to gender identity,” NCQA said.
For the 2024 update, NCQA expanded breast and cervical cancer screening measures to include transgender members.
NCQA also added a social need screening and intervention measure to the 2023 set, encouraging health plans to identify and address social determinants of health among beneficiaries, including food, housing, and transportation needs.
While commercial, Medicare, and Medicaid plans rely on HEDIS measures to compare health plan quality, some measures are specific to public payers.
Only Medicare plans use a HEDIS measure to record follow-up doctor visits for people with multiple high-risk chronic conditions after an emergency department admission. Medicaid plans have specific HEDIS surveys that measure the health conditions of children with chronic diseases.
Medicare Advantage and Part D Star Ratings
CMS uses a star rating system to measure the quality of Medicare Advantage and Part D plans. The ratings help consumers compare health plans and select the one that best meets their needs.
The system rates plans on a five-star scale, with one being the lowest and five being the highest score. The score primarily reflects performance on consumer satisfaction and care quality measures using data from consumer surveys.
Ratings for Medicare Advantage plans are based on five categories:
- Member experience with the health plan
- Customer service performance
- Member complaints about the health plan
- Chronic condition management
- Beneficiary health while enrolled in the health plan
Part D plans are given ratings based on four areas:
- Member experience with the drug plan
- Customer service performance
- Member complaints about the drug plan
- Drug safety and pricing
Medicare Advantage and Part D plans with star ratings of four or higher are considered above-average plans. If a plan receives a rating lower than three stars for three years in a row, the plan is flagged as low-performing.
CMS updates the star rating methodology annually. For the 2023 star ratings, the agency changed the weighting for certain measures and introduced guardrails for measures that have been in the program for over three years. Guardrails restrict the upward and downward movement of a measure’s cut points.
In the 2024 Medicare Advantage and Part D Final Rule, CMS added a health equity index reward to the star rating program to incentivize plans to improve care for beneficiaries with social risk factors.
Following the creation of the quality bonus program, star ratings can also influence Medicare Advantage payments. Medicare Advantage plans with four stars or more receive a 5 percent bonus to their benchmark. In counties with high Medicare Advantage penetration but low traditional Medicare spending, these plans receive a 10 percent bonus.
Payers can achieve higher star ratings by investing in member engagement platforms and developing strategic communications that build relationships with Medicare beneficiaries. Payers can also improve their beneficiaries’ experiences with intuitive reporting services that allow members to provide feedback throughout their health plan year.
Core Quality Measures
The core quality measures, established by the Core Quality Measures Collaborative (CQMC), are a set of performance benchmarks intended to hold payers accountable for the quality of general medical care and specialty services.
CQMC recommends that both public and private payers use the core quality measures. They aim to reduce inefficient quality reporting while providing transparent information about healthcare performance.
There are ten core measure sets that address different areas of healthcare:
- Accountable Care Organization / Patient-Centered Medical Home / Primary Care
- Behavioral Health
- Cardiology
- Gastroenterology
- Human Immunodeficiency Virus / Hepatitis C
- Medical Oncology
- Neurology
- Obstetrics and Gynecology
- Orthopedics
- Pediatrics
Each core set has its own quality measures that pertain to its given specialty. For example, the behavioral health set includes measures on depression screening and unhealthy alcohol use screening. Meanwhile, measures in the neurology set focus on stroke rehabilitation and medication reconciliation.
Core quality measures are specifically designed to promote evidence-based performance and generate valuable information for quality improvement. Metrics also aim to improve consumer decision-making, boost value-based payment and purchasing, reduce variability in measure selection, and decrease a provider’s collection burden and cost.
CMQC reviews the core measure sets annually and also reviews new measures that may be added to the sets.
In 2023, CMQC updated all core measure sets except neurology and medical oncology. The coalition also removed some quality measures that were either no longer evidence-based or no longer significantly enhanced performance.
HEDIS measures, Medicare Advantage Star Ratings, and core quality measures are critical metrics for payers trying to attract and enroll consumers primed for member engagement. Quality performance on these measures and high star ratings signify high-performing health plans and can position payers as the market standard for potential beneficiaries.
This article was originally published on December 21, 2017.
