The National Committee for Quality Assurance has scrapped its old ranking system for health plans and instituted a new ratings system that's similar to what the CMS has implemented for providers and Medicare Advantage plans.
NCQA made the change to be more consistent with the government's strategy for judging healthcare quality and to more accurately represent a health insurer's performance.
“Rankings made sense when there were comparatively few plans measuring and disclosing results,” NCQA spokesman Andy Reynolds said. “But over time, the difference between one ranking's place and another was smaller than the rankings numbers might imply.”
The NCQA recently rated more than 1,000 health plans across three lines of service: commercial, Medicare and Medicaid. Health plans receive a rating between one and five, with five indicating the highest quality. Those ratings are based on member satisfaction, prevention and treatment. Clinical outcomes and measures—such as whether kids got immunizations or whether the blood sugar of diabetic adults was properly managed—were given more weight.
“We're always very conscious of wanting to get at performance,” Reynolds said. NCQA also weighted 9% of the rating on whether the plan was accredited by the organization, he said.
Not-for-profit plans often performed the best across all three categories, especially those located in New England and in Midwestern states near the Great Lakes, according to the NCQA's data released this week. Kaiser Permanente, Capital District Physicians' Health Plan, Harvard Pilgrim Health Care, Tufts Health Plan and UPMC Health Plan all received a five-point rating multiple times.
Many investor-owned insurers had low-rated plans, including Cigna Corp. and WellCare Health Plans. A vast majority of companies were in the middle of the pack with ratings of three or 3.5.
Cigna has 18 commercial plans with a rating of two or lower in the NCQA's ratings for this year. The insurer, which is in the process of being acquired by Anthem, also had 15 commercial plans with a rating of four or higher. Dr. Richard Salmon, Cigna's national medical director, said the low ratings were mostly a matter of incomplete information. The markets with the low-rated plans only included administrative claims data.
“We're comfortable that the care that our customers are receiving is at a high level and is reflected in the results where we do the full comprehensive administrative and hybrid data review,” Salmon said. But, he said, “we will be pushing hard for improvements.”
The CMS' star system for Medicare Advantage plans differs from the NCQA's ratings in one major area: financial incentives. Advantage plans that attain at least four stars receive bonus payments. The rest get nothing extra. Plans that have fewer than three stars for three consecutive years could get kicked out of the Medicare program.
Quality ratings have proliferated throughout healthcare as a means to direct patients toward the hospitals, doctors and health plans that have the best clinical outcomes and the lowest costs. Healthcare researchers wrote this week in JAMA that most quality metrics rely on “professional standards,” but those metrics sometimes “can fail to capture what matters most to each individual.”
“Patients, family members and friends should be able to report whether the patient received what he or she most needed and wanted,” the researchers wrote in the medical journal.