What Is The 5 Star Rating System For Managed Care? | Jane Jackson, RN, CRC | RxEconsult

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What Is The 5 Star Rating System For Managed Care? Category: Healthcare Administration by - October 10, 2016 | Views: 29513 | Likes: 1 | Comment: 0  

CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey:  The CAHPS survey is sent to selected health plan members annually. Survey questions are related to healthcare concerns such as:

a.       Getting needed care

b.       Getting care quickly

c.       How doctors communicate

d.       Health plan customer service

e.       Overall satisfaction with the health plan and healthcare providers

The questions are targeted to the member’s experience and perception related to their personal healthcare needs. Recent numbers indicate CAHPS represents nearly 20% of the overall Star rating for a health care plan. 

HOS (Health Outcomes Survey) survey:  The Health Outcomes Survey (HOS) is conducted annually. Medicare members are targeted. Questions on this survey are related to:

a.       Improving or maintaining physical health

b.       Improving or maintaining mental health

c.       Monitoring physical activity

d.       Improving bladder control

e.       Reducing the risk of falling

This survey targets the member’s personal perception and recollection of how their healthcare was handled during a select period of time. Latest information indicates HOS is just over 10% of the overall Star score for a health care plan. 

Health Plan Operational Data: Some Star ratings are based on data reported to the CMS by health care plans. Self-reported and internal reviews include complaints and appeals rates as well as call center performance, the volume of complaints, and beneficiary disenrollment. 

Part D measures developed by the Pharmacy Quality Alliance are now included among the measures for Star ratings. These measures include the percentage of compliance with medication administration, prescribing high-risk medications, pharmacy costs, and many others.

HEDIS, CAHPS, and HOS represent nearly 60% of the overall Star rating so Health Plan Operational Data and Pharmacy Part D measures would represent 40% of the Star rating. The average managed care Star rating has increased from 2.5 Stars in 2012 to 4 Stars in 2015.  Beginning in 2016, managed care plans with less than a 3 Star rating for three consecutive years will be issued a notice of non-renewal of the contract for the following year.

About The Author

Jane Jackson has more than  25 years experience in healthcare, including hospital-based care, home health, and managed care. She enjoys sharing her knowledge and can she be reached at Jane.Jackson@DailyDoseHQ.com. Also visit her blog, Daily Dose HQ.

Also Read:

What Is Managed Care?


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