Medicaid — Get Ready for Change Now

The Centers for Medicare and Medicaid Services (CMS) have recently proposed a new rating system for all Medicaid plans. Traditionally, states have been administering the Medicaid plans with input from CMS. While many states already have a quality measurement system in place, the states’ systems are widely different and follow different measurement/rating systems. But with the new regulation, CMS is proposing tighter controls around quality control.

This is a good thing. Sure this means improvements for the overall industry and potential work for you. But it also means improvement to your way of doing business. You might be asking yourself, why? how? We’ll explain why the proposed system could mean improvements to your business and how to achieve them sooner than later.

Specifically on why this will improve overall care; the new rating system will strengthen the quality measurements and promote improvement with:

  1. Transparency on quality of care. This is a widely recognized tool for driving improvements in care.
  2. Alignment with other systems of care such as Medicare (MA) and the Marketplace. This will result in a simplified and integrated approach to quality measurement and improvement.
  3. Consumer and Stakeholder Engagement. This is particularly important when designing an approach to measuring quality for Medicaid managed care, including Long Term Care (LTSS).
  4. Finally, the proposed rating system will assist states in more easily identifying plans that have a commitment to providing high quality care.

What Does This Mean for Each State?

That change is coming and states will be required to comply by either;

  1. Following CMS guidelines,
  2. Going above and beyond the CMS guidelines or,
  3. Creating their own quality metric system – with CMS approval.

In any of these cases, compliance will require;

  • Each state to collect data from each Managed Care Organization (MCO), Prepaid Ambulatory Health Plan (PIHP) and Prepaid Inpatient Health Plan (PAHP) with which it contracts. This includes, at a minimum, data evidencing the MCO’s, PIHP’s or PAHP’s performance on the measures.
  • The state to apply the methodology established by CMS to these performance measures to determine a quality rating or ratings for each MCO, PIHP, or PAHP.
  • The state to utilize the Medicare (MA) five-star rating for MCOs, PIHPs or PAHPs exclusively serving dual eligibility in place of the established quality rating system.
  • The state to prominently display the quality rating of each MCO , PIHP and PAHP on its website.

The Good News for You

There are benefits for the overall industry, for members and your own organization. The new rating system is proposed to be developed on 3 summary indicators:

  • Clinical Quality Management
  • Member Experience
  • Plan Efficiency, Affordability and Management

Beneath these 3 summary indicators there are a set of 8 domains that represent important aspects of quality:

  1. Clinical Effectiveness
  2. Patient Safety
  3. Care Coordination
  4. Prevention
  5. Access
  6. Doctor and Care
  7. Efficiency and Affordability
  8. Plan Service

Each respective domain has a set of associated performance measures (19 clinical and 10 survey measures) which all factor in to create a rating that consumers may use when evaluating health plan options.

The new rating system will be aligned with the rating system currently in place for the QHP’s offered through Marketplaces, minimizing the burden on health plans that operate in both markets and provide data for the various quality rating systems.

Also, there is an extended timeframe for implementation – CMS expects to refine the standards over the next 3-5 years. This allows ample time to make adjustments well before any deadlines.

What Can You Do Now?

First and foremost, don’t wait 3 years to take action! The earlier you start, the earlier you will see the benefits. It is important to work efficiently and thoroughly from the start. Set priorities according to the measures with the most impact. Adopt a strategy to go after improving the measures across the entire portfolio of plans Medicare, Medicaid, QHP, or Commercial. Whether it is Medicaid, Medicare or a QHP plan, the underlying measures are the same. Improving your performance on these measures will help to improve your Stars rating (for Medicare) and QRS (QHP rating). Next, develop a comprehensive QI strategy and be on a lookout for the coming changes.

Finally, while there are many performance measures in the proposal, SDLC can assist in your preparedness by performing a readiness assessment of the measures. We can align your measures with that of the Medicare/QHP Plans from a business and financial standpoint – well in advance of any deadlines. This will provide numerous improvements even before the new rating system is implemented.

Start taking action now to stay ahead of the curve.

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