As we count down to the December 14th deadline for states to declare whether they’ll pursue a state-based exchange and submit their blueprints, we’re seeing some progress on another important front: the quality improvement requirements for exchanges. On November 27, 2012, HHS released a Request for Information Regarding Health Care Quality for Exchanges in preparation for implementing important quality-related requirements for qualified health plans participating in exchanges. The implementation of the quality requirements will be critical to achieving the vision of a health system that is not only more affordable for individuals, families, employers, and government, but also serves to improve overall quality of care and population health – goals outlined in the National Strategy for Quality Improvement in Health Care (National Quality Strategy).
As my CHIR colleagues JoAnn Volk and Sabrina Corlette have pointed out in their paper, The Role of Exchanges in Quality Improvement: An Analysis of the Options, states have a number of opportunities to use the exchange as a catalyst for delivery system reform and quality improvement throughout the insurance marketplace. Let’s review what the Affordable Care Act says on this front:
- Quality reporting for private health insurance (Section 2717 of the Public Health Service Act) requires the Secretary of HHS to develop quality reporting requirements for non-grandfathered individual and group health plans and policies, both inside and outside of exchanges, with respect to covered plan or coverage benefits and health care provider reimbursement structures that improve health outcomes, reduce hospital readmissions, improve patient safety, and implement wellness and health promotion activities.
- In outlining requirements for qualified health plans (Section 1311 of the ACA) states that in order for plans to be certified as Qualified Health Plans through the exchanges, they must implement a quality improvement strategy, defined as “a payment structure that provides increased reimbursement or other incentives”, to improve health outcomes, reduce hospital readmissions, improve patient safety, implement wellness and health promotion activities, and reduce health disparities.
- Medical loss ratio (Section 2718 of the Public Health Service Act): Health insurers are now being held to higher quality standards through the ACA’s medical loss ratio rule, which requires plans to spend at least 80 percent of premium dollars on the provision of health care services or on quality improvement activities. In rulemaking, HHS specified the types of quality improvement activities that would count for purposes of the MLR calculation: namely, programs that improve health outcomes and reduce health disparities, prevent hospital readmissions, improve patient safety, reduce medical errors, lower rates of infection and mortality, increase wellness and health promotion, and increase the use of health care data through information technology (45 C.F.R. § 158.150).
- Quality rating system, enrollee satisfaction, and health plan value: The ACA also directs the Secretary of Health and Human Services to establish a quality rating system and enrollee satisfaction survey system, as well as developing a methodology for calculating the value of a health plan.
Thoughtful and robust implementation of these provisions – as well as ongoing monitoring – will be critical to achieving a health system that fully utilizes proven strategies to improve health and reduce costs. After all, it’s not a given that health insurance will cover services just because they are proven to make people healthier or improve quality – as colleagues Mila Kofman and Katie Dunton recently found in an analysis of the implementation of the new tobacco cessation coverage requirements in the ACA. After closely examining 39 insurance contracts to determine how well they were adhering to the new ACA rules requiring coverage of evidence-based tobacco cessation services, they found that, “While 36 of the 39 analyzed insurance contracts indicate they are providing coverage for tobacco cessation or are providing coverage consistent with the USPSTF recommendations, 26 of these contracts also included language excluding tobacco cessation from coverage entirely or partially.”
Another analysis of coverage of colonoscopies under the ACA’s prevention benefit, co-authored by CHIR colleagues Kevin Lucia and Katie Keith, found that “there is significant variation in whether insured consumers receive colorectal cancer screening with no cost-sharing.” Given that there is overwhelming evidence for the benefit of both tobacco cessation and colonoscopies in preventing serious illness and death, it is going to take a lot of work to make sure that evidence-based guidelines are being incorporated into coverage policies in a way that matters for consumers.
We’ll be watching closely as commenters respond to the quality RFI, which asks critical questions that will guide how exchanges are used to drive quality improvements, and ultimately, better health outcomes. With states like California, Oregon, and Rhode Island already moving towards a proactive approach that integrates their health insurance exchanges into an overall vision for how to improve health and reduce overall costs, we at CHIRblog are especially looking forward to finding out how states respond to CMS’s question about quality efforts that states are pursuing, including how they are using existing quality measures, using public reporting or transparency efforts to display health care quality information, or aligning quality reporting requirements inside and outside the exchange marketplace.
Speaking of quality of life, it’s going to be a busy December for health policy wonks – so take your vitamins, try to get some sleep, and, as my mother frequently admonishes, don’t forget to breathe. Count on CHIRblog to bring you all the latest in our “State of the States” series!