There’s an old saying that people tell others when something goes wrong or things aren’t going well. They say, “Well, at least you still have your health.” Ultimately, it never makes anyone feel better, but the thought is that people need to put things in perspective. Money, material processions, none of these things are as important as being vital, healthy and alive.
People shouldn’t mess around when it comes to their health, and the government isn’t either. In an effort to ensure that health plans were offering quality service to their members, the Centers for Medicare & Medicaid Services (CMS) introduced their star rankings for health plans. These ratings are designed to rank health plans based on the quality of care they provide for their members and areposted on Medicare.gov so that Medicare members can reference them when selecting a plan.
How are the star rankings calculated? Well, health plans are required to submit Healthcare Effectiveness Data and Information Set (HEDIS) information, which measure care and service. This information is then carefully vetted by the National Committee for Quality Assurance (NCQA) for accuracy and passed on to CMS, whose vendor partners, like Edaptive Systems, utilize algorithms to assign the star ratings. Other measures of health care are also included in the final analysis.
Although this system has been in place for years, the stakes have recently been upped to drive health plans to embrace higher-quality care. CMS has instituted bonuses to provide an incentive for health plans to improve their star ratings thus improving the quality of care that they offer to their members.
Obviously, with budgets being tight and government spending being slashed due to the ongoing economic downturn, it’s important to ensure that these bonuses are truly going to health plans that are providing the type of quality service and preventive medicine that is reflected in their submitted HEDIS information. Checks and balances have to be in place to ensure that this information is accurate and true-to-life.
To help provide an additional layer of analysis in addition to the rigorous systems in place, CMS is working to establish a Web application where health plans will be required to submit patient-level data which is checked for accuracy. Essentially, they’re being required to provide the actual data about the patient, the tests or treatments they received and other information that can back up the summary data that they submitted originally. By analyzing this patient-level data against the summary data, CMS can better analyze the information they receive from health plans and ultimately ensure that the star ratings that they’re assigning are accurate.
This results in two very positive outcomes. First, the bonus incentives being given to health plans with high star ratings are accurate and the government is giving money to plans that are truly working to deliver high quality of care and preventive medical tests and procedures. Second, by eliminating any waste and providing a tough set of checks and balances, the program can truly drive lower performing health plans to improve their quality of care.
One shouldn’t mess around with their health, and a big part of preserving health is high quality healthcare. CMS’s star ratings can ensure that people are receiving quality care and the preventive medical tests and procedures that ensure they’ll stay vital and healthy. By creating this online system, CMS is enabling an incentive program that will drive improved care for Medicare patients. They’re also simultaneously preventing inaccurate claims by health plans and working to reduce government waste.