With proposed rules governing each state's health insurance exchanges under review, a prominent quality organization is urging the Centers for Medicare & Medicaid Services to make sure that employers and the public can understand what they are buying.
Left on their own, "we don't think these (state) exchanges will come up with common levels of quality" that enable consumers to make appropriate comparisons, said Sarah Thomas, Vice President of Public Policy and Communications for the NCQA, the National Committee on Quality Assurance.
For example, she said, it's important that the exchanges provide comparison information that includes not just the monthly premiums, but other costs such as co-pays, deductibles, and share of costs, all of which could significantly affect the total price tag of each benefit plan.
"Value is not just about low premiums, but instead both total costs and high quality care together," the organization said in a Sept. 28 letter to the Centers for Medicare & Medicaid Services. "It is critical to make clear that low premiums can mask low quality. Low premiums also can mislead consumers who do not understand that low premium plans may have higher cost sharing that can be a serious barrier to affordable, quality care."
The Patient Protection and Affordable Care Act required CMS to establish rules by which each exchange should be run. The 36-page proposed rules were published in the Federal Register Aug. 17, and the public has until Oct. 31 to submit comments.
Health insurance exchanges are a key piece of the health reform law because they are intended to offer coverage to an estimated 15.8 million enrollees in 2014, when they must begin, to 30.6 million by 2019, including many who are denied or can't afford coverage today.
"Our experience in working with states and their quality report cards is that they do choose different things to focus on," Thomas said. But if states allow plans to report on different measures, the consumer will not know how to judge one plan from another.
"It would be a shame if these systems don't end up delivering better quality of care."
CMS should also specify how health insurance carriers may describe their plans. "We strongly advise against letting plans simply submit essays describing their quality strategies, although we recognize that some qualitative review may be necessary in early stages of evaluation.
"In our experience we have found that essays can be misleading and subject to inconsistent rating by different evaluators." The plans should be required to "provide documentation that supports the statements and structure information to allow for comparisons."
Thomas said in an interview that two states that already have their exchange material are Utah and Massachusetts. "In Utah, we understand they have every intention to put quality ratings on their website but they haven't done it yet. And in Massachusetts, it's available but it's not prominent."
Thomas said that it's important for states to offer printed materials for health plan comparisons within their exchanges, in addition to what might be posted on a website. That's because in places like some rural areas of Mississippi, they don't have broadband. And, "you're going to need people on the ground to help consumers sort through choices, and for areas where people may not have a high level" of health literacy, and may not understand a term like "deductible."
Additionally, websites and printed materials as well as personnel to guide consumers through their selection process should be in multiple languages and dialects to reflect regional variation.
In its letter to CMS, the NCQA recommends that each state be required to evaluate qualified health plans based on a core set of quality measures that tightly specify procedure and diagnosis code level.
The NCQA has developed the well-known HEDIS measures, Healthcare Effectiveness Data and Information Set, and that set or other accredited sets should be applied across all exchange choices.
The NCQA also recommends that:
- Exchanges use information that is collected annually beginning in June 2015 on 2014 exchange enrollees.
- Exchanges be independently audited to ensure accuracy and comparability of results.
- Include measures relevant and prevalent to the exchange population and already in use under public and privately sponsored healthcare coverage arrangements.