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[Federal Register Volume 78, Number 223 (Tuesday, November 19, 2013)]
[Notices]
[Pages 69418-69426]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-27649]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3288-NC]

Patient Protection and Affordable Care Act; Exchanges and 
Qualified Health Plans, Quality Rating System (QRS), Framework Measures 
and Methodology

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice with comment.

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SUMMARY: This notice with comment describes the overall Quality Rating 
System (QRS) framework for rating Qualified Health Plans (QHPs) offered 
through an Exchange. The purpose of this notice is to solicit comments 
on the list of proposed QRS quality measures that QHP issuers would be 
required to collect and report, the hierarchical structure of the 
measure sets and the elements of the QRS rating methodology. In 
addition, this notice solicits comments on ways to ensure the integrity 
of QRS ratings, and on priority areas for future QRS measure 
enhancement and development.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on January 21, 2014.

ADDRESSES: In commenting, refer to file code CMS-3288-NC. Because of 
staff and resource limitations, we cannot accept comments by facsimile 
(FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address only: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-3288-NC, P.O. Box 8016, 
Baltimore, MD 21244-8016.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address only: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-3288-NC, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written only to the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.

    If you intend to deliver your comments to the Baltimore address, 
call telephone number (410) 786-9994 in advance to schedule your 
arrival with one of our staff members.
    Comments erroneously mailed to the addresses indicated as 
appropriate for hand or courier delivery may be delayed and received 
after the comment period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Nidhi Singh Shah, (301) 492-5110, for 
general information. Elizabeth Flow-Delwiche, (410) 786-1718, for 
matters relating to the Quality Rating System.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments 
received before the close of the comment period are available for 
viewing by the public, including any personally identifiable or 
confidential business information that is included in a comment. We 
post all comments received before the close of the comment period on 
the following Web site as soon as possible after they have been 
received: http://www.regulations.gov. Follow the search instructions on 
that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

I. Background

A. Legislative Background

    The Patient Protection and Affordable Care Act of 2010 (Pub. L. 
111-148) as amended by the Health Care and Education Reconciliation Act 
of 2010 (Pub. L. 111-309) (collectively referred to as the Affordable 
Care Act) establish Affordable Insurance Exchange or Exchange (also 
known as a Health Insurance Marketplace or Marketplace) within each 
state. Qualified individuals and qualified employers in each state will 
be able to shop for affordable health insurance through Exchanges.
    The Department of Health and Human Services (the Secretary) holds 
primary responsibility for establishing the standards and guidelines 
for the Exchanges. The Affordable Care Act provides States with the 
flexibility to establish and operate their own Exchange (State-based 
Exchange). However, if a state elects not to establish a State-based 
Exchange or if a state will not have an Exchange that is operational by 
January 1, 2014, pursuant to section 1321(c)(1) of the Affordable Care 
Act, the Secretary will establish and operate a Federally-facilitated 
Exchange in those states. The Affordable Care Act and applicable 
Exchange regulations establish that health plans offered through an 
Exchange must meet specific standards to be certified as QHPs and to 
offer coverage in an Exchange beginning in January 2014.
    The Affordable Care Act also requires the Secretary to develop a 
number of reporting requirements to support the delivery of quality 
health care coverage offered in the Exchanges. Specifically, sections 
1311(c)(3) and (c)(4) of the Affordable Care Act direct the Secretary 
to develop--(1) a system that rates qualified health plans (QHPs) based 
on the relative quality and price; and (2) an enrollee satisfaction 
survey system that assesses the level of enrollee experience (that is, 
consumer experience) with QHPs. Because we believe that QHP consumer 
experience is an important part of rating the overall quality of a QHP, 
we intend to use some of the information collected from the Enrollee

[[Page 69419]]

Satisfaction Survey in the Quality Rating System (QRS).
    In addition to consumer experience, we believe that the QRS should 
provide ratings of QHPs based on health care quality, health outcomes, 
and cost of care. We intend for all QHP issuers to report data at the 
product level for the initial years of QRS implementation (for example, 
at the Health Maintenance Organization level or Preferred Provider 
Organization level). We expect QHPs to provide product-level quality 
performance data for the QRS in general topics, such as clinical 
effectiveness of care, patient safety, care coordination, prevention of 
disease and illness, access to care, member experience, plan services 
and efficiency, and cost reduction. The QRS ratings should demonstrate 
sound, reliable, and meaningful information on the performance of QHPs 
to ultimately support informed decisions by consumers.
    We have already promulgated regulations at 45 CFR 155.200(d) that 
direct Exchanges to oversee implementation of the QRS, and 45 CFR 
156.200(b)(5) \1\ that directs QHP issuers to report health care 
quality information to an Exchange. In this notice, we describe the 
overall QRS framework and the factors that guided the development of 
the QRS. We solicit comments on the QRS measure sets for QHPs offered 
to adult individuals and families, (QRS) and for child-only QHPs (Child 
QRS), the hierarchical structure of the measure sets, and the elements 
of the rating methodology. We also solicit comments on ways to ensure 
the integrity of QRS ratings, and the identification of priority areas 
for future QRS measure enhancement and development.
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    \1\ Patient Protection and Affordable Care Act; Establishment of 
Exchanges and Qualified Health Plans; Exchange Standards for 
Employers, 77 FR 18310 (Mar. 27, 2012) (to be codified at 45 CFR 
parts 155, 156, & 157).
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    In future rulemaking, we intend to propose requirements for QHPs 
and Exchanges regarding the collection and submission of specific 
quality-related information. In addition, we intend to provide future 
technical guidance for QHP issuers and Exchanges related to the QRS 
measure specifications, detailed rating methodology guidelines, and 
data reporting and procedures.

B. QRS Goals and Principles

    We believe that the overarching goal of the QRS is based on two 
fundamental tenets: (1) Providing comparable and useful information 
regarding the quality of QHPs offered through the Exchanges to inform 
consumer and employer choice; and (2) facilitating regulatory oversight 
of QHPs with regard to the quality standards set forth in the 
Affordable Care Act. Consequently, we believe that the QRS should 
provide QHP ratings based on health care quality and outcomes, consumer 
experience, and cost. We developed the following five general QRS 
principles to guide the design of the QRS:
     The QRS should produce QHP quality performance information 
to encourage the delivery of higher-quality health care services, 
expand access to care, and improve health outcomes for QHP enrollees.
     The QRS should provide sound, reliable, and meaningful 
quality-related QHP information, which could be used by consumers when 
comparing health plans, by QHPs for quality improvement, as well as by 
Exchanges and CMS for QHP certification and regulatory oversight 
activities.
     The QRS should reflect the goals of the National Strategy 
for Quality Improvement in Health Care priorities,\2\ which includes 
reporting cross-cutting performance areas (that is, patient safety, 
prevention, population health, patient engagement, patient experience, 
and efficient resource use). The QRS should also facilitate reporting 
on conditions or procedures of significant prevalence and importance 
(for example, heart disease or breast cancer screening).
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    \2\ See Report to Congress: National Strategy for Quality 
Improvement in Health Care available at http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm.
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     The QRS measures set should be evidence-based and align, 
to the maximum extent possible, with priority measures currently 
implemented in federal, state, and private sector programs to minimize 
QHP issuer burden. We have drawn on our experience administering the 
Medicare Advantage 5-star rating system in developing this framework, 
and intend that the development and evolution of the QRS should be 
public and transparent and should allow for flexibility to incorporate 
changes in measures and methodologies as medical treatments and 
technology evolve and the Exchanges mature.

C. QRS Framework

    We have developed a framework for creating, implementing, 
maintaining and revising the QRS. The overall framework consists of the 
following components that are guided by the QRS goals and principles:

 Performance Information
 Rating Methodology

    In total, there are ten associated elements that further clarify 
the Performance Information and Rating Methodology components (see 
Table 1 below).

[[Page 69420]]

[GRAPHIC] [TIFF OMITTED] TN19NO13.003

    The goals and principles for the QRS serve as the common thread 
throughout the QRS framework. The Performance Information component 
consists of four elements: (1) Measures Selection; (2) Hierarchical 
Structure; (3) Organization of Measures; and (4) Data Strategy. The 
Measures Selection element represents the process for selecting and 
evaluating the measure sets of the QRS. The Hierarchical Structure 
element establishes how the QRS measure sets are organized for scoring, 
rating, and reporting purposes. The Organization of Measures element 
establishes the approach to create composites, domains, and summary 
indicators ratings. The Data Strategy element, which is discussed in 
section IV, refers to the procedures for how the measures data will be 
collected, calculated, submitted and will help to inform how data will 
be displayed.
    The Rating Methodology component aims to define how QHPs will be 
scored and compared, and as proposed, consists of six elements:
     Aggregation Rules would be used to determine how measures 
should be combined to create useful quality information on health care 
areas such as diabetes care or preventive health care.
     Sampling and Attribution would establish the selection 
criteria for determining appropriate population samples that yield 
reliable and valid information.
     Scoring would be the process used to convert the raw QRS 
measures data to points or percentiles on a common numeric scale.
     Performance Classification would be used to assign values 
to the QHP scores; these values would then be used to categorize the 
QHP's performance.
     Population and other adjustments would refer to changes 
made to raw data or measures to remove potential bias introduced by 
factors that are not modifiable by the QHP.
     Peer Groups would be used to establish a benchmark dataset 
for comparison of the individual QHP in the performance classification 
work, most often based on the geographic and time period considerations 
(for example, current annual distribution of all plans nationally).

II. Performance Information Component

A. Measures Selection

    The process used to select the QRS measure sets included a review 
of existing health plan measures, so that the QRS measures promote 
consistency and harmonization across State, Federal government entities 
(for example, CMS) and private-sector efforts. Our review included 
national measure sets that were relevant to the intended purpose of the 
QRS and incorporate health plan measures such as the Initial Adult 
Medicaid Core Set of Health Care Quality Measures, Initial Core Set of 
Children's Health Care Quality Measures, Clinical Quality Measures for 
Eligible Professionals, and Medicare Part C and Part D Reporting 
Requirements, as well as a variety of other quality measurement 
programs, including health plan accreditation programs.\3\ We believe 
it's important that measures, in the initial years, be specified for 
health plans (rather than specified for health care providers) to 
ensure reliable data, reduce QHP burden and facilitate consumer use and 
comprehension.
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    \3\ In addition to the programs and measure sets mentioned 
above, CMS included the following program measure sets in the 
environmental scan: eValue8, Consumer Reports Health Plan Rankings, 
Office of Personnel Management Federal Employee Health Benefit 
Program; Health Plan Accreditation programs: URAC, National 
Committee for Quality Assurance, Accreditation Association for 
Ambulatory Health Care; State Health Monitoring Programs: Maryland 
HealthChoice Consumer Report Card, California Healthcare Quality 
Report Card, NY Electronic Quality Assurance Reporting Requirements, 
Maryland Health Plan Report Card, California Medi-CAL Health Plan 
Quality Ratings; State Based Exchanges: Oregon Health Insurance 
Exchange, New York State Health Benefit Exchange California Health 
benefits Exchange
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    Measures selection and measure set evaluation criteria were 
developed using the National Quality Forum (NQF) Measure Evaluation 
Criteria and the Measures Application Partnership (MAP) Measure-
Selection Criteria.4 5

[[Page 69421]]

The measure selection criteria, which represent industry-tested 
criteria and were supported as measure inclusion criteria based on 
discussions with stakeholders and public comment received in response 
to a Request for Information (RFI),\6\ focuses on the following areas:
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    \4\ National Quality Forum. ``Measure Evaluation Criteria, 
November 2012.'' accessed January 23, 2013, http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx.
    \5\ Measure Applications Partnership. ``MAP Working Measure 
Selection Criteria and Working Guide.'' National Quality Forum, 
December 2012.
    \6\ Request for Information Regarding Health Care Quality for 
Exchanges: http://www.gpo.gov/fdsys/pkg/FR-2012-11-27/pdf/2012-28473.pdf.
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     Importance: the extent to which the measure is important 
to making significant gains in health care quality, improving health 
outcomes, has a high impact (high priority) and is relevant to the 
Exchange population and benefits covered by QHPs.
     Performance Gap: the extent to which the measure 
demonstrates opportunities for performance improvement based on 
variation in current health plan performance.
     Reliability and Validity: the extent to which the measure 
produces consistent (reliable) and credible (valid) results.
     Feasibility: the extent to which the data related to the 
measure are readily available or could be captured without undue burden 
and can be implemented by QHPs.
     Alignment: the extent to which the measure is included in 
one or more existing federal, state or private sector health plan 
quality reporting programs.
    The QRS measure set evaluation criteria were applied to identify 
measurement gaps in the QRS measure sets and helped to ensure that the 
proposed QRS measure sets as a whole would best meet the needs of 
consumers and the Exchanges.
    The draft QRS measure sets were evaluated to determine the extent 
to which the measures were NQF-endorsed and aligned with the NQS 
priorities. Relevance to the Exchange consumer was evaluated by 
assessing whether the measure set addressed clinical conditions of 
moderate or high prevalence or high disease burden (applicable only to 
the clinical care measures) and whether the measure sets identified the 
needs of the consumer related to health-plan operations and 
satisfaction. Relevance of the QRS measure sets to QHPs was evaluated 
by assessing how well each of the sets addressed the benefit categories 
required of QHPs as part of the Affordable Care Act essential health 
benefits requirement; \7\ and if the sets complemented other 
information used by the Exchange to support consumer comparison of 
health plans or to assist with QHP certification and plan monitoring. 
The comprehensiveness of the draft QRS measure sets were assessed by 
examining the measures and ensuring that, to the extent possible based 
on the availability of health-plan specified measures, the sets 
included an appropriate mix of clinical care measure types, such as 
structure, process and outcome measures; experience of care measures; 
and measures that assess cost/resource use/appropriateness of care and 
plan management. The draft QRS measure sets were evaluated for the 
degree to which they promoted equitable access and treatment by 
considering healthcare disparities, and ways in which the measure sets 
can capture data to promote strategies that address variations in care. 
In addition, the draft QRS measure sets were evaluated based on the 
percentage of measures that demonstrated parsimony, an efficient use of 
resources, including--(1) the ready availability of automated data 
(available through existing claims, administrative, survey, and health 
plan management databases); or (2) whether the measures are publicly 
reported or currently in use as contractual performance standards 
between plans and public/private purchasers or between plans and 
provider organizations or as in accordance with statutory or regulatory 
requirements.
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    \7\ Patient Protection and Affordable Care Act; Standards 
Related to Essential Health Benefits, Actuarial Value, and 
Accreditation; Final Rule 78 FR 12834 (Feb. 25, 2013) (to be 
codified at 45 CFR parts 147, 155 and 156).
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    The draft measure sets were revised and the proposed QRS measure 
sets were created following this evaluation. The proposed QRS measure 
sets were also evaluated and reviewed internally by CMS, externally by 
industry and stakeholders and in a field test using available health 
plan data. Listening sessions were also conducted for insurers, states 
and consumer groups.
    Although the measures contained in the QRS are consistent with the 
state-of-science for measuring health care quality, science and 
technology do not yet allow us to measure or represent the quality of 
all care delivered through the QHPs. Therefore, the QRS measure set 
should not be viewed as representative of all care delivered by QHPs.

B. Individual Measures for QRS and Child-Only QRS

    QHPs offered in the Exchange may provide family/adult self-only 
coverage or child-only coverage (child-only QHPs) and therefore, there 
are two proposed measure sets; the QRS measure set (for family and 
adult self-only coverage) and a Child-only QRS measure set. Both 
measure sets were selected based on the above described key criteria. 
We solicit comments on the proposed measures in the QRS and Child-only 
QRS listed below in Table 2. The proposed QRS measure set for family/
adult self-only coverage consists of a total of 42 measures--29 
clinical measures, which encompass health care topics of clinical 
effectiveness, prevention, access and efficiency; and 13 Consumer 
Assessment of Healthcare Providers and Systems[supreg] (CAHPS) survey 
measures, which encompass topics such as member experiences with the 
QHP, providers and health care services, including preventive care. The 
QRS measure set addresses the essential health benefits for which 
health plan measures are currently available. The majority (76 percent) 
of the measures are presently NQF-endorsed and address all six National 
Quality Strategy priorities. Approximately, 83 percent of the QRS 
measures are included in at least one of the reviewed Federally-
established measure sets (for example, Office of Personnel Management 
Federal Employee Health Benefit (OPM FEHB), CMS Medicare Stars, CMS 
Adult Medicaid Core Set,\8\ CMS Initial Children's Core Set,\9\ 
Medicare Part C&D Plan Reporting). The remaining measures are used in 
other state based and private sector health plan reporting programs 
such as Consumer Reports Health Plan Rankings \10\ or through 
accreditation. QHPs offering family or adult self-only coverage would 
be required to report on all 42 measures in the QRS measure set.
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    \8\ Initial Core Set of Health Care Quality Measures for Adults 
Enrolled in Medicaid (Medicaid Adult Core Set). February 2013.
    \9\ SHO: 13-002. Letter to State Health Official and 
State Medicaid Director. Re: 2013 Children's Core Set of Health Care 
Quality Measures. January 24, 2013.
    \10\ http://www.consumerreports.org/health/insurance/health-insurance-plans.htm.
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    The Child-only QRS measure set consists of a total of 25 measures--
15 clinical measures and 10 CAHPS measures. The Child-only measure set 
includes a combination of process and outcome measures. The Child-only 
QRS measure set addresses many of the essential health benefits. The 
majority of the measures (84 percent) are NQF-endorsed and largely 
address the six National Quality Strategy priorities. Approximately 80 
percent of the measures are included in either the OPM FEHB Set or the 
CMS Initial Children's Core Set. As with the QRS measure set, the 
remaining measures in

[[Page 69422]]

the child-only set are used state based and private sector health plan 
reporting programs. Child-only QHPs would be required to report on all 
25 measures in the Child-only QRS measure set.

                          Table 2--Proposed Measure Sets for the QRS and Child-Only QRS
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               Measure title                         NQF ID \11\                  QRS           Child-only QRS
----------------------------------------------------------------------------------------------------------------
Adolescent Well-Care Visits...............  Not currently endorsed......                  X                   X
Adult BMI Assessment......................  Not currently endorsed......                  X   ..................
Adults' Access to Preventive and            Not currently endorsed......                  X   ..................
 Ambulatory Health Services.
Annual Dental Visit.......................  1388........................                  X                   X
Annual Monitoring for Patients on           Not currently endorsed......                  X   ..................
 Persistent Medications.
Antidepressant Medication Management......  0105........................                  X   ..................
Appropriate Testing for Children With       0002........................                  X                   X
 Pharyngitis.
Appropriate Treatment for Children With     0069........................  ..................                  X
 Upper Respiratory Infection.
Avoidance of Antibiotic Treatment in        0058........................                  X   ..................
 Adults with Acute Bronchitis.
Breast Cancer Screening...................  Not currently endorsed......                  X   ..................
CAHPS--Aspirin Use and Discussion.........  Not currently endorsed......                  X   ..................
CAHPS--Coordination of Members' Health      Not currently endorsed \12\.                  X                   X
 Care Services.
CAHPS--Cultural Competency................  Not currently endorsed \13\.                  X                   X
CAHPS--Customer Service...................  0006........................                  X                   X
CAHPS--Flu Shots for Adults...............  0039........................                  X   ..................
CAHPS--Getting Care Quickly...............  0006........................                  X                   X
CAHPS--Getting Needed Care................  0006........................                  X                   X
CAHPS--Global Rating of Health Plan.......  0006........................                  X                   X
CAHPS--Medical Assistance With Smoking and  0027........................                  X   ..................
 Tobacco Use Cessation.
CAHPS--Plan Information on Costs..........  0006........................                  X                   X
CAHPS--Rating of All Health Care..........  0006........................                  X                   X
CAHPS--Rating of Personal Doctor..........  0006........................                  X                   X
CAHPS--Rating of Specialist Seen Most       0006........................                  X                   X
 Often.
Cervical Cancer Screening.................  0032........................                  X   ..................
Child and Adolescent Access to PCPs.......  Not currently endorsed......  ..................                  X
Childhood Immunization Status.............  0038........................                  X                   X
Chlamydia Screening in Women (Ages 16-20).  0033........................  ..................                  X
Cholesterol Management for Patients With    Not currently endorsed......                  X
 Cardiovascular Conditions: LDL-C Control
 (Dl).
Cholesterol Management for Patients With    Not currently endorsed......                  X
 Cardiovascular Conditions: LDL-C
 Screening.
Colorectal Cancer Screening...............  0034........................                  X   ..................
Controlling High Blood Pressure...........  0018........................                  X   ..................
Diabetes Care: Eye Exam (Retinal)           0055........................                  X   ..................
 Performed.
Diabetes Care: Hemoglobin A1c (HbA1c)       0575........................                  X   ..................
 Control http://www.qualityforum.org/Home.aspx.
    \12\ Only one question within the CAHPS Coordination of Members' 
Health Care Services composite is currently endorsed 
(0007): ``Did your personal doctor seem informed and up-to-
date about the medical care you got?''. The remaining questions in 
the composite are new and have not yet been endorsed.
    \13\ One of the questions within this CAHPS composite was 
modified from CAHPS Clinician and Group 2.0, Adult Supplemental (NQF 
1904) and the other question is new.
    \14\ Measure includes only one indicator of the NQF-endorsed 
measure.
    \15\ Measure includes only one indicator of the NQF-endorsed 
measure for the child-only QRS.
    \16\ Measure includes only one indicator of the NQF-endorsed 
measure.
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C. Organization and Hierarchical Structure of the QRS Measures

    The Performance Information component of the QRS framework guided 
the proposed structure and hierarchy, as well as the measures that will 
be included within each level of the hierarchy. In order to be most 
useful to consumers, rating systems that can present a large collection 
of measures must be organized into a hierarchical structure. We 
considered organizing the measures in a manner to maximize the 
approachability and understandability of the information provided by 
the QRS. We are proposing hierarchical structures for the QRS and 
Child-only QRS that allow consumers to easily use information from the 
QRS in their health plan comparisons for selection of a QHP in the 
Exchange. We solicit comments on the proposed hierarchical structures 
outlined in Tables 3 and 4 below.
    The fundamental building block of the QRS structure is the 
individual indicator or measure. The hierarchical structures include 
composites, which represent the combination of two or more individual 
indicators or measures that result in a single score. Measures are 
grouped into composites so large amounts of information can be 
streamlined and reported in formats that are easy for consumers to 
comprehend. Grouping measures into composites also helps to reduce 
random variability, differentiate performance across health plans and 
provide meaningful information to the consumer. Not all measures in the 
QRS are part of a composite. Table 3 provides the organization of the 
proposed QRS measure set for family/adult self-only coverage. The QRS 
organizes measures and composites into a set of eight domains that 
represent unique and important aspects of quality: (1) Clinical 
Effectiveness, (2) Patient Safety, (3) Care Coordination, (4) 
Prevention, (5) Access, (6) Doctor and Care, (7) Efficiency and 
Affordability (8) Plan Services. The domains are grouped into three 
summary indicators which align with CMS priority areas: (1) Clinical 
Quality Management; (2) Member Experience; and (3) Plan Efficiency, 
Affordability and Management. The summary indicators organize the 
domains into broad categories that the consumer may use when evaluating 
health plan options. All three summary indicators would then be grouped 
into a single Global Rating. The Global Rating is a score that 
summarizes all measures, composites and domains in the hierarchical 
structure of the QRS.

                                         Table 3--Proposed QRS Structure
----------------------------------------------------------------------------------------------------------------
       QRS summary indicator               QRS domain             QRS composite             Measure title
----------------------------------------------------------------------------------------------------------------
Clinical Quality Management........  Care Coordination.....  No Composite..........  CAHPS--Coordination of
                                                                                      Members' Health Care
                                                                                      Services.
                                     Clinical Effectiveness  No Composite..........  Medication Management for
                                                                                      People With Asthma.
                                                             Behavioral Health.....  Antidepressant Medication
                                                                                      Management.
                                                                                     Follow-Up After
                                                                                      Hospitalization for Mental
                                                                                      Illness: 7 days.
                                                                                     Follow-Up Care for Children
                                                                                      Prescribed ADHD
                                                                                      Medication: Initiation
                                                                                      Phase.
                                                             Cardiovascular Care...  Cholesterol Management for
                                                                                      Patients With
                                                                                      Cardiovascular Conditions:
                                                                                      LDL-C screening.
                                                                                     Cholesterol Management for
                                                                                      Patients With
                                                                                      Cardiovascular Conditions:
                                                                                      LDL-C control (
                                                                                      Dl).
                                                                                     Controlling High Blood
                                                                                      Pressure.
                                                             Diabetes Care.........  Diabetes Care: Eye Exam
                                                                                      (Retinal) Performed.
                                                                                     Diabetes Care: Hemoglobin
                                                                                      A1c (HbA1c) Control pre>
```