CMS Establishes Rating System for Obamacare Insurance Plans

Published October 30, 2019

Exchange health plans will be ranked on a five-star scale in three categories: member experience, medical care, and plan administration.

Ratings will be based on data issuers submit on past performance and are being provided for the 2020 Open Enrollment Period, which begins November 1, 2019.

Apples to Oranges

Physicians less tied to insurance providers are skeptical toward the ratings, saying they will deter patients from quality health care options not just within the exchanges but also outside them.

“In general, attempting to judge the quality of care using ICD-10 [International Classification of Diseases] codes are an exercise in futility,” said Philip Eskew, a physician, attorney, founder of DPC Frontier, and policy advisor to The Heartland Institute, which publishes Health Care News. “Third-party payer efforts to justify their own existence are at the heart of the problem.”

Comparisons within a small geographical region could be helpful, but there is too much variability in documentation and services in different areas, resulting in “an apples to oranges comparison,” says Brian Forrest, a physician and founder of Access Healthcare.

“In one county, you might have access to multiple radiology centers and specialists necessary for certain screenings; in another county you might not have a place where patients can get a mammogram or colonoscopy for 20 miles,” Forrest said. “This decreased access may falsely score a plan lower simply because of what is available where most of their insured patients live.”

Insurance Bias

In judging plans on member experience, ratings will be based on member satisfaction surveys and reported ease of access to appointments and services. That will place some providers at a disadvantage over which they have no control, Forrest says.

“In rural or underserved communities, it may be more difficult to get in for appointments simply due to less providers or facilities,” Forrest said.

The second category, “medical care,” involves care management such as regular screenings, vaccines, and the monitoring of certain health conditions. Forrest says this measure is likewise problematic, because it is based on claims data, not patient histories.

“For example, I provide free flu shots to all of my patients without a copay or filing any insurance,” Forrest said. “According to those patients’ health plans, they did not get a flu shot since it was never billed to insurance. The plan or the provider might get a lower rating due to misleading or false data.

“I get letters from insurance companies sometimes telling me they recommend I check a lab test on a patient because it looks like it has not been done in a year,” Forrest said. “Many times, it has been done four times in that year, but since the insurance plan did not get charged, they think it was never done.”

Insurers’ Cost Focus

The third category is plan administration, based on information access and appropriate treatment and testing. Forest says this too could be shortsighted.

“The problem many doctors would have here is that the insurance company is telling them what to order,” said Forrest. “Many times, this is based on keeping the insurance companies’ costs down, rather than what the patient actually needs,” Forrest said.

Ashley Bateman ([email protected]writes from Alexandria, Virginia.