Managed Care and Star Rating SystemManaged care organizations (MCOs) are required to meet Medicare and Medicaid quality benchmarks. 

What is Managed Care?

To quote Wikipedia, the term managed care is used in the United States to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care. 

Managed care organizations (MCOs) offer healthcare plan options for Medicare and Medicaid recipients to register for in order to receive enhanced benefits.  These benefits could be lower co-payments, more transportation benefits, increased pharmacy coverage or perhaps more comprehensive preventive care. 

Report Card

The infamous 5-star rating system is how managed care organizations are graded.  This rating is calculated by the National Committee for Healthcare Quality (NCQA) for the Center for Medicare and Medicaid Services (CMS). 

Ratings are displayed on the CMS website.  Being a 3-star plan lined up all neatly under the 5, 4.5, 4, 3.5 Star companies simply cannot be a good marketing position.  There are perks for being a 5-star plan – increased payments for each member and the ability to enroll members year-round.   

Star Rating Components

Star ratings are obtained through three major reporting programs. The Health Outcomes Survey (HOS) – completed by members to rate how their healthcare needs were met by their insurance plan and provider. 

The Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) – completed by the members rating services they received from the insurance plan and provider.  CAHPS includes components reported by the managed care organization themselves.  Then, the topic of this discussion - the Health Effectiveness Data Information Set (HEDIS).

What is HEDIS?

HEDIS is a major part of the Star rating of a managed care organization.  Over 90% of all US health plans use this tool to measure performance and quality provided to beneficiaries.  There are over 80 measures ranging from obtaining an adult Body Mass Index to counting pre-natal visits for an OB patient to lead screening of children. 

The NCQA Technical Specification manual, published yearly, describes each measure in detail.  Measures are different depending on whether the member is an enrollee in Medicare, Medicaid or both – often called duals.

When is HEDIS?

HEDIS is conducted year-round.  Managed care organizations utilize both internal and external staff to gather information throughout the year to satisfy the measures.  There are two phases – pre-HEDIS and HEDIS.  Pre-HEDIS is from June to December 31st.  This time-frame allows reviews of provider and member compliance with HEDIS measures. 

December 31st is the official cut-off date for most measures.  Procedures, testing, assessments after this date are not reportable for the targeted year but may certainly be useful for the next HEDIS season.  Never ever deter a provider from attempting to satisfy HEDIS measures. 

Official HEDIS season is from March through May.