Washington's Strategic Move to Develop Its Own Quality Improvement Strategy
In 2022, Washington began tailoring its QIS requirements to improve insurers’ performance on quality metrics. Washington designates specific QRS clinical measurements for which insurers must provide the state with data and requires them to implement a quality improvement strategy incorporating these measurements. For 2024, carriers will be required to submit QRS measurements for cervical cancer screening and antidepressant medication management.
Part of Washington’s strategy is designed to target health disparities. Historically, there have been racial and ethnic disparities in cervical cancer screening rates and antidepressant medication adherence. In 2023, Washington began requiring issuers to present both measurement results stratified by race and ethnicity to identify health disparities. (CMS requires insurers to report both measurements under the federal QRS program but does not require these measurements to be stratified by race and ethnicity.) The state was able to take this important step because it has prioritized the collection of enrollee race and ethnicity data. The marketplace already has made significant strides working with insurers to collect directly reported data and has established still higher reporting standards for future years.
California’s New Quality Transformation Initiative Lays a Foundation for Data Stratification
Covered California has rolled out an innovative Quality Transformation Initiative (QTI) and is building into the program ways to reduce health disparities. Through the QTI program, California penalizes insurers who place below the 66th national percentile for four QRS-required clinical measures: controlling high blood pressure, comprehensive diabetes care, colorectal cancer screening, and childhood immunization status. Penalties will be collected into a Quality Transformation Fund and used to finance activities that positively impact population health. Separately, carriers are also penalized for failing to report enrollees’ spoken and written language and collecting less than 80 percent of enrollees’ directly reported race and ethnicity data.
California intends to use stratified race and ethnicity data to build health equity accountability into the QTI program. California will evaluate whether carriers meet the 66th percentile threshold for each OMB-designated racial and ethnic group. (Race and ethnicity groups without sizable populations will be combined in an “all other members” group.) The financial penalties imposed on carriers will be adjusted based on the size of the respective racial or ethnic population groups. Overall population measurements can mask differences in outcomes for various demographics. By not only requiring the data to be stratified but also holding carriers to the same threshold, California's health equity methodology emphasizes the importance of ensuring that no racial or ethnic group is subjected to lower health care quality standards.
The implementation of health equity accountability is targeted for the 2026–28 QTI contract period. In the interim, Covered California mandates that insurers provide details on how they will address health disparities. For example, insurers may state the measures they are implementing to collect demographic data or strategies to ensure consumers can access health care in their preferred language.
Looking Ahead
In the reoccurring discussions about social justice, advocates have emphasized that equity cannot be optional, a principle that holds true in the realm of care quality. Washington and California highlight opportunities for other state-based marketplaces to strengthen their quality programs. These efforts also suggest that CMS could raise standards across SBMs by continuing to incorporate health equity in the QIS and QRS programs. CMS should implement its plans to mandate carriers to use directly reported race and ethnicity data for enrollees and continue to increase the number of QRS clinical measures that must be stratified by race and ethnicity. To promote transparency and allow for accountability, CMS should publicly report issuers’ stratified QRS data and provide details on the QIS programs that issuers submit to address health care disparities.
Quality reporting programs that do not rely on data stratified by race and ethnicity run the risk of making inaccurate assumptions about the actual state of health care services in America. Such oversight not only conceals existing disparities but also contributes to the perpetuation of racial discrimination within the U.S. health care system.
