When you buy insurance you have the option of purchasing rated or unrated plans. Is there much of a difference? The answer is YES! It is wise to buy a rated plans because in order to be rated they must pass specific guidelines and measures, then they are given a rank. The rank is based on score. Commercial, Medicare, and Medicaid health plans are ranked separately.
So how do you interpret ratings, and scores?
Score: The highest possible score is 100, including up to 15 points (based on compliance with accreditation standards) if plan is accredited by the National Committee for Quality Assurance (NCQA).
Basically the score tells you how well the plan measures up in clinical and service performance in four major categories: access to care, overall member satisfaction, prevention, and treatment.
These four categories are broken down into numerous measures, these are what define performance in each category. There are 42 measures for commercial plans, 33 for Medicare plans, and 39 for Medicaid plans.
So, let’s take a look at some of the measures for commercial plans as well:
COMMERCIAL PLAN TERMS
– Access to care:
There are 6 measures
o Getting needed care,
o Getting care quickly,
o Well-child visits in the first 15 months,
o Well-child visits in the 3rd through 6th years,
o Primary care from ages 7 to 11,
o Adolescent well-care visits.
– Overall member satisfaction:
There are 7 measures
o Doctors’ communication skills,
o High rating of personal doctor or nurse,
o Rating of specialist,
o High rating of healthcare received,
o Claims processing,
o Customer service,
o High rating of plan services.
– Prevention
There are 10 measures
o Early childhood immunizations,
o adolescent immunizations,
o chlamydia screening in young women,
o timeliness of prenatal and postpartum care,
o regular mammograms and Pap tests,
o colorectal screening,
o strep test for children diagnosed with sore throat;
o appropriate use of antibiotics for children with common cold.
– Treatment
There are19 measures
o Appropriate asthma medication;
o effective diabetes care (checking eyes, testing and controlling blood sugar, checking and controlling LDL cholesterol, monitoring kidney disease);
o administering and continuing beta blocker after heart attack;
o controlling high blood pressure;
o advising smokers to quit and offering strategies and medications;
o effective care for depression (providing suitable specialist in acute depression, medicating depression appropriately over short and long term);
o following up after hospitalization for mental illness;
o initiating and continuing treatment for alcoholism and substance abuse.
Ok, then there are individual measures as well:
– Getting care: Getting needed care; getting care quickly.
– Getting needed care: Percentage of members most recently surveyed who said getting needed care from their personal doctor or a specialist was not a problem.
– Getting care quickly: Percentage of members most recently surveyed who said delays in getting care were not a problem.
– Children and adolescents: Percentage of children who had at least six well-child visits from birth to 15 months old; percentage of children age 3, 4, 5, or 6 who had a well-child visit during the year reported; percentage of children ages 7 to 11 who had a well-child visit during the current or previous year; percentage of members age 12 to 21 who had at least one comprehensive well-care visit.
– High rating of personal doctor or nurse: Percentage of members most recently surveyed who answered 8, 9, or 10 when asked to rate their personal doctor or nurse from 0 (worst possible) to 10 (best possible).
– High rating of healthcare received: Percentage of members most recently surveyed who gave plan an 8, 9, or 10 when asked to rate the quality of care from 0 (worst possible) to 10 (best possible).
– Satisfaction with plan services: Claims processing; customer service; high rating of plan services.
– High rating of plan services: Percentage of members most recently surveyed who gave plan an 8, 9, or 10 when asked to rate the quality of all services from 0 (worst possible) to 10 (best possible).
– Child and adolescent immunizations: Percentage of children who got all recommended immunizations by their second birthday; percentage of adolescents who got all recommended follow-up immunizations by their 13th birthday.
– Women’s reproductive health: Chlamydia screening in young women; timeliness of prenatal and postnatal care.
– Cancer screening: Regular mammograms; regular screening for cervical cancer; regular screening for colorectal cancer.
– Regular mammograms: Estimated percentage of women ages 50 to 69 who had at least one mammogram in the previous two years..
– Colorectal cancer screening: Percentage of adults ages 50 to 80 who have been tested for colorectal cancer.
– Antibiotic overuse in children: Percentage of children ages 3 months to 18 years diagnosed with a common cold who were not prescribed an antibiotic for three days; percentage of children ages 2 to 18 diagnosed with sore throat who were prescribed an antibiotic and got a strep test.
– Diabetes: Estimated percentage of members with diabetes who got blood glucose and LDL cholesterol tests and eye exams, whose blood glucose and LDL cholesterol was controlled, and whose kidney disease was monitored.
– Glucose testing: Estimated percentage of members ages 18 to 75 with type 1 and type 2 diabetes who got blood glucose testing.
– Eye exams: Estimated percentage of members ages 18 to 75 with type 1 and type 2 diabetes who had a retinal eye exam.
– Heart disease: Administering and continuing beta blocker after heart attack; controlling high blood pressure; advising smokers to quit and offering both strategies and medications for doing so.
– Mental and behavioral health: Percentage of members seeing suitable specialist to manage, appropriately medicate, and appropriately follow up acute depression; follow up appropriately after hospitalization for mental illness; initiate and continue treatment for alcoholism and substance abuse.
– Medicate depression appropriately: Percentage of members newly diagnosed with depression who received antidepressant medication for 12 weeks after the initial diagnosis.
As you can see, rigorous screening and measures are done, and the ratings are based on the findings, thus going with a rated plan means ensuring better service, care, and satisfaction.