To help determine the value of health care provided by qualified health plans (QHPs) that will contract with Health Insurance Exchanges, the Centers for Medicare and Medicaid Services (CMS) is seeking information on best practices in health plan quality management and reporting.

Through a Request for Information (RFI), CMS seeks information on existing quality measures and rating systems, strategies and requirements for quality improvement, health care purchasing strategies to promote care redesign and patient safety, and effective methodologies to measure health plan value.  CMS is also asking for recommendations on the most effective ways to measure and publicly report QHP quality of care and align this with existing quality improvement initiatives.  Overall, CMS wants QHP quality reporting to further the ambitious goals of the HHS National Quality Strategy.

The Affordable Care Act (ACA) health reform law places a variety of quality-related requirements on health insurers offering qualified health plans (QHPs) in the new Health Insurance Exchanges.  In particular, ACA requires:

  • QHPs to implement quality improvement strategies, enhance patient safety through specific contracting requirements, and publicly report quality data.
  • CMS to develop and administer a quality rating system and an enrollee satisfaction survey system, the results of which will be available to consumers shopping for insurance plans in the Health Insurance Exchanges.
  • CMS to develop a methodology for calculating the value of health plans, both those inside and outside the Exchanges.

The following are CMS’ 15 questions. The RFI is a great opportunity for experts, thought leaders, states, and prospective QHPs to help CMS design the value ranking system that will be used to inform consumers and small employers as they buy coverage in the Health Insurance Exchanges.

CMS Questions on Health Plan Quality Management and Reporting:

Understanding the Current Landscape:

1. What quality improvement strategies do health insurance issuers currently use to drive health care quality improvement in the following categories:

  • Improving health outcomes
  • Preventing hospital readmissions
  • Improving patient safety and reducing medical errors
  • Implementing wellness and health promotion activities
  • Reducing health disparities

2. What challenges exist with quality improvement strategy metrics and tracking quality improvement over time (for example, measure selection criteria, data collection and reporting requirements)? What strategies (including those related to health information technology) could mitigate these challenges?

3. Describe current public reporting or transparency efforts that states and private entities use to display health care quality information.

4. How do health insurance issuers currently monitor the performance of hospitals and other providers with which they have relationships? Do health insurance issuers monitor patient safety statistics, such as hospital acquired conditions and mortality outcomes, and if so, how? Do health insurance issuers monitor care coordination activities, such as hospital discharge planning activities, and outcomes of care coordination activities, and if so, how?

Applicability to the Health Insurance Exchange Marketplace:

5. What opportunities exist to further the goals of the National Quality Strategy through quality reporting requirements in the Exchange marketplace?

6. What quality measures or measure sets currently required or recognized by states, accrediting entities, or CMS are most relevant to the Exchange marketplace?

7. Are there any gaps in current clinical measure sets that may create challenges for capturing experience in the Exchange?

8. What are some issues to consider in establishing requirements for an issuer’s quality improvement strategy? How might an Exchange evaluate the effectiveness of quality improvement strategies across plans and issuers? What is the value in narrative reports to assess quality improvement strategies?

9. What methods should be used to capture and display quality improvement activities? Which publicly and privately funded activities to promote data collection and transparency could be leveraged (for example, Meaningful Use Incentive Program) to inform these methods?

10. What are the priority areas for the quality rating in the Exchange marketplace (for example, delivery of specific preventive services, health plan performance and customer service)? Should these be similar to or different from the Medicare Advantage five-star quality rating system (for example, staying healthy: screenings, tests and vaccines; managing chronic [long-term] conditions; ratings of health plan responsiveness and care; health plan members’ complaints and appeals; and health plan telephone customer service)?

11. What are effective ways to display quality ratings that would be meaningful for Exchange consumers and small employers, especially drawing on lessons learned from public reporting and transparency efforts that states and private entities use to display health care quality information?

12. What types of methodological challenges may exist with public reporting of quality data in an Exchange? What suggested strategies would facilitate addressing these issues?

13. Describe any strategies that states are considering to align quality reporting requirements inside and outside the Exchange marketplace, such as creating a quality rating for commercial plans offered in the non-Exchange individual market.

14. Are there methods or strategies that should be used to track the quality, impact and performance of services for those with accessibility and communication barriers, such as persons with disabilities or limited English proficiency?

15. What factors should HHS consider in designing an approach to calculate health plan value that would be meaningful to consumers? What are potential benefits and limitations of these factors? How should Exchanges align their programs with value-based purchasing and other new payment models (for example, Accountable Care Organizations) being implemented by payers?

For more information, click here to read the CMS Request for Information (PDF).  Responses are due by 5 pm EST on Thursday, December 27, 2012.


Kip Piper is a Medicare, Medicaid, and health reform consultant, speaker, and author.  A senior consultant with Sellers Dorsey and Fleishman-Hillard, Kip advises health plans, hospitals and health systems, states, drug and device manufacturers, and investment firms throughout the U.S.  For more, visit  Follow on Twitter at @KipPiper and connect with Kip on LinkedIn.