Quality Rating (Star Rating)

What Are Quality Ratings (Star Ratings)?

A quality rating (star rating) is a designation of quality given to health services by the Centers for Medicare & Medicaid Services (CMS). CMS retrieves personal and medical information through surveys and clinical data to achieve a rating of quality for care, services, and overall experience. They produce a CMS star rating for every plan they cover. Providers, as well as the insured, play a part in developing an over-all cms star rating for a particular provider. Quality ratings are derived from a combination of data points taken across three different categories but encompass other important information as well.

The grade provided by the quality rating is usable and current. It offers an enrollee a window into the way the plan operates and how it compares to other plans being offered in the marketplace. Choosing the right plan is as simple as looking at the quality ratings of available Quality Health Plans (QHPs) in your marketplace. You can choose by the CMS star rating alone or you can research your QHP choices further. The system is designed to show the best-rated services, help avoid the pitfalls, and educate the public at the same time.

Rating the Marketplace for Healthcare

The Health Insurance Marketplace, also knowns as the “exchange, helps people enroll in affordable, but quality, healthcare plans. The exchange is a federally run program, but some states offer their own healthcare marketplaces as well but without a quality rating system. The federal program is available to all under the Affordable Care Act (ACA) and runs Open Enrollment until December, 15th annually. The enrollment process, limits of coverage, availability of plans, and the overall quality of a plan plays an important role in how successful the marketplace is.

One way the current federal marketplace is succeeding is by getting into new pricing negotiations for services and drugs. The next is by having a quality rating on what services are already available. This was done to inform enrollees what has worked best in the past for others and may work well for them in the future.

Who Assigns CMS Star Ratings?

The Centers for Medicare and Medicaid services. The Centers for Medicare and Medicaid Services has a goal of raising the health status of the general public by improving the quality of healthcare. The way to increase the level of care is to raise accountability among healthcare providers and insurance companies alike. One of the ways that CMS is increasing transparency in the healthcare industry is by going right to the insured for their opinion. The work done by CMS provides the public with an important service.

The surveys, the data crunching, the results; all done to create a quality rating (star rating) that enrollees can access before enrolling in a plan or receiving care. The system is achieving its goals within some open marketplaces, but not every state has initiated the program. CMS plans on rolling out its system in all open insurance marketplaces as soon as they negotiate how it works within those states’ markets who do not currently operated under the quality star rating system.

Quality Health Plans (QHPs)

A QHP is an insurance plan that covers an enrollee with essential healthcare. These plans will adhere to cost limits for the insured. These basic, but powerful, QHP benefits will include access to preventative medicine, hospitalization, psychological care, substance abuse and more. These are at the core of a QHP. What separates the QHP for itself is the level of coverage available. Here you can choose a plan that moves up or down the service scale. Bronze, silver, gold, and platinum levels will cover more or less of your out of pocket expenses. Be sure to research any plan, even if it is a QHP. The options change dramatically with each level of insurance provided.

Quality Rating Categories

Member Experience

A healthcare providers’ success can be greatly measured by the experience of the patient. Fortunately the way the healthcare system sees accountability today is different than before. Now there is more patient interaction. Their voices are being heard and listened to. Some of this comes from the star rating assigned to a provider by CMS. Some of it comes from the providers stepping up to the plate during this time of change and accountability.

Some additional topics covered when speaking about a health plan members’ experience is how easy was it to obtain care? Do your providers provide the best care compared to other, local caregivers? Is your healthcare up to date, i.e., modern equipment and being knowledgeable on the latest procedures? How informed is your doctor on your status? Does your healthcare direct you from one doctor to the other?

Medical Care

Medical care is more than curing what ails you. Staying healthy longer is one of the directives of CMS and CMS Star Ratings. Enrollees have new information to make informed decisions. The decision to choose one healthcare plan over the other should have nothing to do with cost, but treatment when compared to cost.

An average affordable healthcare plan should cost about 9.65% of the income of an average American. It should also come with a quality rating to let the enrollee know past experiences. The 9.65% cost should allow an enrollee enough room to find a service provider and plan that fits into their lifestyle and can be accessed from where they live. Medical is not so much what treatment you receive, but how you begin to heal and how quickly you get back to normal.

Plan Administration

Much of the cost of healthcare can be directly blamed on the administration of benefits. When a hospital has more insurance administrators than they do beds, the cost of the plan will be dramatically higher because the cost for doing business is so high. Quality ratings include how a plan operates, and how expensive the costs of doing business are vs. the price to cure the sick.

A CMS quality rating will uncover a bad actor and reveal a good one at the same time. When the enrollee has enough power to make an informed decision because of a cms star rating, the entire system is improved.