The Next Step: Improving Health Care Quality and Reducing Cost in the Medicaid Program

THE NEXT STEP: IMPROVING HEALTH CARE QUALITY AND REDUCING COST IN THE MEDICAID PROGRAM

MARCH 2014

Executive Summary improvement processes and provisions in AS THE HEALTH CARE SYSTEM EVOLVES, federal law, expanding them to all states and policymakers have focused on quality all delivery system modalities. As an measurement and improvement initiatives to important next step in advancing the National find common-ground solutions to deliver Quality Strategy for the Medicaid program, better quality care, access to providers, and, this reporting mechanism would establish a ultimately, lower costs. While the Medicare baseline for the quality of provided care, program has benefited from federal identify quality gaps in the Medicaid program, initiatives for comprehensive measurement and institute a standardized method to and improvement, such measure quality and efforts for the Medicaid The Medicaid program must be promote quality improvement. program largely have efficient and effective, and must focused on the state In recognition of level. provide value to its beneficiaries overburdened state and to those who fund it. But the Medicaid Medicaid agencies, the program is a vital Without a comprehensive Partnership proposes component of the U.S. measurement and reporting federal funding to assist health care system, system, we cannot know whether in the implementation of the reporting system and providing care and this is the case, nor can we critical services to the collection of metrics more than 60 million determine where improvements from plans and providers. patients. To ensure may be needed. These entities would that the Medicaid report to their respective program continues to evolve and improve, states according to an established set of the Partnership for Medicaid supports the measures, which would evolve with time and development of a comprehensive, stakeholder input. In addition, the Centers for standardized quality measurement and Medicare & Medicaid Services (CMS) would reporting program to promote improvement develop a standardized reporting in the quality of care for our nation’s most infrastructure to allow states to report their vulnerable populations. data to CMS. Information gleaned from comprehensive mandatory reporting would The Partnership for Medicaid recommends be available to Congress, stakeholders, and the development of a uniform, state-level the public, providing policymakers with the reporting mechanism for the Medicaid information needed to make evidence-based program. This mechanism will build on decisions about improvements to the existing quality measurement and Medicaid program.

As with all health care programs, Medicaid Medicaid as a Learning Laboratory must be efficient and effective, and must The Medicaid program is perhaps the provide value to its beneficiaries and to those country’s greatest experiment in federalism. who fund it. Without a comprehensive Medicaid’s unique federal nature means that measurement and reporting system, we “the Medicaid program” is a misnomer. In cannot know whether this is the case, nor fact, the 50 states, the District of Columbia, determine where improvements may be and five U.S. territories run 56 different needed. This proposal represents an Medicaid programs. 2 With respect to services important step toward that goal. provided and populations covered, all states comply with the minimal requirements I. Background and Statement of Need established by the federal government. Above

Established nearly 50 years ago, Medicaid is a the minimum, each state determines unique state/federal partnership that eligibility levels for the populations it covers, annually provides health care and other selects additional covered services, and critical services to more than 60 million decides how services will be financed and vulnerable people. Several populations with delivered (e.g., through fee-for-service or very different health care needs and managed care). utilization patterns are served through the Medicaid’s diffuse structure has opportunities Medicaid program. These populations include and challenges. Each Medicaid program is pregnant women, children, older adults (aged different, and overall program structure 65 and over), people with disabilities, and, provides significant opportunity for state- particularly in those states that are expanding level and even regional innovation, making Medicaid, adults under 65 years of age. Medicaid one of the great laboratories in Despite the challenge of providing health care health care. The variation in Medicaid to a diverse and often difficult-to-reach programs, however, means that it is population, Medicaid has lower per-capita difficult to compare programs across costs than most private insurance and lower states. Each state has a different mix of overhead costs than Medicare. 1 The quality eligible populations in different types of and costs of care provided through Medicaid delivery systems. Further, many services must be well understood to ensure the value provided to Medicaid beneficiaries – such as of this program to beneficiaries and to mental health services – may be funded society. and/or delivered at the local level (e.g., The federated model… allows for state Community Mental Health Centers). Challenges in integrating federal, state, and experimentation, but also creates local data, in addition to a lack of consistent challenges in measuring and assuring measurement, make it difficult to measure high-quality and affordable care for the relative benefit of Medicaid coverage all Medicaid beneficiaries. across the country.

1 Park, E., and Broaddus, M. Correcting Five Myths About Medicaid. Center on Budget and Policy Priorities. 2 Hereafter, we use “states” to refer to Medicaid http://www.cbpp.org/cms/index.cfm?fa=view&id=40 programs, although these programs also exist in the 23. Accessed 24 September 2013. District of Columbia and five U.S. territories.

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Ensuring Better Health Care, Healthy requirements, states require managed care People and Communities, and Lower organizations with which they contract to Costs report standard Healthcare Effectiveness In 2011, the Department of Health and Data and Information Set (HEDIS®) Human Services (HHS) adopted the National performance measures and to meet Strategy for Quality Improvement in Health requirements for access. But these reporting Care (National Quality Strategy) to create and access measures, as well as the national goals and priorities to guide local, populations enrolled in managed care, vary state, and national efforts to improve the by state. These differences limit the validity of quality of health care in the United States. The cross-state quality comparisons. three-part aim of the National Quality The federated model of Medicaid and the Strategy is to achieve healthier people and Children's Health Insurance Program (CHIP) communities, better health care, and allows for state experimentation, but also affordable care through six priorities: making creates challenges in measuring and assuring care safer, ensuring person- and family- high-quality and affordable care for all centered care, promoting effective Medicaid beneficiaries. Congress recognized communication and coordination of care, that the unique needs of the Medicaid promoting the most effective prevention and population were not fully met by existing treatment for the leading causes of mortality, Medicare, or Medicaid managed care, quality working with communities to promote wide improvement measures. As a result, federal use of best practices to enable healthy living, law established the new Medicaid Quality and making high-quality care more Measurement Program to develop core affordable. quality measures for adult health care under Much of the federal quality improvement Medicaid (Section 1139B of the Social activity historically has occurred in the Security Act). This section mirrors aspects of Medicare program. While providers serving the federal investment in Medicaid and CHIP the Medicaid program participate in various quality improvement contained in the CHIP quality measurement activities (see Appendix Reauthorization Act (CHIPRA, Section 1139A for a summary of the kinds of current quality of the Social Security Act).4 improvement activities), improvement efforts The development of core quality measures for in the Medicaid program largely focus on adult health care under Medicaid and the state-level requirements. CHIPRA quality provisions are important first Medicaid managed care—one delivery system steps. But measurement and reporting area with significant quality measurement requirements vary across states and are requirements—provides services to voluntary. Additionally, existing measures do approximately half of Medicaid enrollees not adequately address all of the domains of through comprehensive, risk-based managed quality; all sub-populations of Medicaid 3 care plans. Pursuant to federal primary care case management and limited-benefit plans. 3 Approximately 71 percent of Medicaid enrollees receive some type of service through a managed care 4 New funding for the quality improvement activities arrangement, which CMS defines to include authorized under CHIPRA expired September 30, comprehensive, risk-based managed care as well as 2013.

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beneficiaries (e.g., children, pregnant women, lower costs. Efforts to improve the quality of and frail elderly); or all settings in which care currently are gaining tremendous these beneficiaries receive care. These momentum and broad support from the measurement gaps and variation in reporting private and public sectors. 7,8 Plans and also inhibit the ability of Medicaid providers serving Medicaid beneficiaries, stakeholders to nationally examine quality of including safety net providers, lead these care, access to care, beneficiary health, and efforts. Transforming the U.S. health system patient satisfaction across populations. to be more efficient and effective is critical in these times of constrained resources. Quality Federal policymakers are rightly interested in improvement is central to achieving this goal investigating opportunities to improve and is predicated on quality measurement. Medicaid to ensure that it provides access to cost-effective, high-quality health care.5,6 The Partnership for Medicaid supports the With the Medicaid expansion that took effect development of a comprehensive quality in January 2014, the Partnership for Medicaid measurement and reporting program for seeks to work with policymakers to find Medicaid to create a consistent, innovative solutions to measure and, as standardized method of reporting, necessary, improve the quality of the care measuring, and promoting improvement provided to beneficiaries. With limited in the quality of care for our nation’s most information about the quality and benefit of vulnerable people. Patients and Medicaid coverage and services, changes to beneficiaries deserve access to the highest- the Medicaid program have often focused on quality coverage available; and there is cost-shifting to states and providers rather always room for improvement within any than on improving care and value. This cost- program, including Medicaid. The Partnership shift can have significant negative impacts on believes that the development of a beneficiary access to care and other comprehensive Medicaid quality reporting unintended consequences. program that measures and ultimately advances Medicaid in the following three key The Partnership for Medicaid believes that a areas will accelerate its improvement: health care system built on a strong foundation and supported by quality measurement and improvement initiatives is critical to achieve common-ground solutions that lead to better quality, better access, and

5 One of the overall charges of the Medicaid and CHIP 7 The Department of Health and Human Services. CMS Payment and Access Commission (MACPAC) is the 2012 Annual Report on the Quality of Care for Children responsibility to conduct analyses of many Medicaid- in Medicaid and CHIP. Medicaid. related issues, including quality of and access to care. http://www.medicaid.gov/Medicaid-CHIP-Program- Several reports available at www.macpac.gov address Information/By-Topics/Quality-of- aspects of these issues. Care/Downloads/2012-Ann-Sec-Rept.pdf. Accessed 21 November 2013. 6 See investigations into how to modernize the program, such as the May 2013 “Making Medicaid Work” 8 MACPAC. June 2013 Report to the Congress on blueprint released in 2013 by House Energy and Medicaid and CHIP. Google Docs. Commerce Committee Chairman Fred Upton (R-MI) https://docs.google.com/viewer?a=v&pid=sites&srcid and Senate Finance Committee Ranking Member Orrin =bWFjcGFjLmdvdnxtYWNwYWN8Z3g6NWE3MTM2N Hatch (R-UT). WU4NjhhNDVmYQ. Accessed 21 November 2013.

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1) Quality of care for Medicaid II. Detailed Recommendations beneficiaries: Clinical standards and the appropriate delivery of health care services The Partnership for Medicaid recommends are important to achieve effective, high- the development of a uniform, state-level quality health care and better health. For reporting mechanism for the Medicaid and Medicaid beneficiaries in particular, delivery CHIP9 programs that builds on existing of the right services, in the right setting, at the measures and the provisions in federal law right time can generate significant savings associated with quality measurement and over time to states, the federal government, improvement. As an important next step in and taxpayers—in addition to providing high- advancing the National Quality Strategy for quality health care. the Medicaid program, this reporting mechanism would be used to establish a 2) Access to care for Medicaid baseline understanding of the quality of care beneficiaries: Low-income and minority provided, identify quality gaps within the populations are significantly more likely to Medicaid program, and institute a report barriers to accessing needed health standardized method to measure quality and care services. Patients with public insurance promote quality improvement. are more likely than their privately insured counterparts to delay and even forego Principles for Measurement and necessary medical and dental care and use of Reporting prescription medicines due to challenges Federal quality including cost, language, transportation, and 1) Comprehensiveness: measurement and reporting programs should availability of providers. These access provide a full picture of quality for all barriers negatively influence personal and Medicaid beneficiaries, including: societal health while driving up costs and the unnecessary utilization of emergency • all subpopulations (pregnant women, services. Access measures are critical children, older adults, people with disabilities, and newly insured adults components of a robust platform for in Medicaid expansion programs); improving health care quality, improving • all settings of care (outpatient, health, and decreasing costs. inpatient, subacute, etc.); 3) Patient experience among Medicaid • all delivery systems (managed care, beneficiaries: The way patients interact with fee for service, accountable care organizations, and primary care case their providers, and their unique experiences management); in receiving care, can impact patient • and all dimensions of quality (safety, compliance, adherence and effectiveness of timeliness, effectiveness, efficiency, treatment regimens, and resource utilization. equity, and patient centeredness). In fact, studies find that patient-centered This proposal seeks to build a framework for approaches to care improve health status. such a comprehensive program. The Measures of patient experience with care are Partnership recognizes it will take time to a critical aspect of quality and cut across develop a robust reporting program. measures specific to health conditions.

9 Hereafter, the use of term “Medicaid” can be understood to include CHIP where applicable.

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2) Appropriate Adjustment in Comparing accompanied by timely feedback reports to Results: Medicaid beneficiaries are providers and plans to inform their practices frequently complex patients who are often and activities. To ensure provider willingness not only low-income but also medically to report quality data, any data collected from underserved. Measures included in a federal individual providers should be protected quality measurement and reporting program, from legal discovery, as is currently the to the extent possible, need to be practice for data reported to Medicare Quality appropriately risk adjusted to take the Improvement Organizations. Medicaid patient populations into account. Furthermore, social determinants of health We recognize that the implementation of a often play a significant role in the health comprehensive reporting strategy will status of Medicaid patients, especially as require federal support at all levels. This compared to other, non-Medicaid-eligible support includes: individuals. Performance measures must • Federal funding for further development factor in the multitude of barriers and of applicable measures for all Medicaid obstacles arising from such social beneficiaries, recognizing the wide variation determinants of health that may impact both in health care needs of the various the baseline and expected improvement for subpopulations served by the Medicaid such individuals. Appropriate risk adjustment program for severity of illness and social factors is • Federal incentives to states to report on especially important when comparing results across populations such as Medicaid and non- applicable measures and develop the Medicaid individuals. necessary infrastructure to do so • Federal financial support to Medicaid 3) Appropriate Balance of Measurement providers and plans to support necessary and Costs/Burden: The costs of collection and reporting of measures to state measurement and reporting to providers and Medicaid agencies, as well as the underlying states should be coupled with improvements infrastructure needed for reporting in health and health care. • The development of a federal reporting 4) Stakeholder Input: Measure sets should infrastructure be developed and maintained in a way that • Technical assistance to states and includes stakeholder input. The NQF providers to aide in standardized reports Measures Application Partnership, development of the National Committee for Four-Step Process to Comprehensive Quality Assurance HEDIS®, and Partnership State Reporting and Accountability: for Patients are possible models for such a process. Establishment of the Succinct Common 5) Data Use: Information collected for Reporting Set (Target Date: Federal Fiscal measure reporting must continue to meet all Year 2015): The Reporting Set should be Health Insurance Portability and reported at the state level, allowing for Accountability Act of 1996 (HIPAA) privacy assessment of overall program activity as requirements. Measure reporting must be well as activity by delivery service modality (e.g., managed care, fee-for-service,

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accountable care organizations, and primary Development of Federal Reporting care case management) using a standardized Infrastructure (Target Date: Federal Fiscal format to be developed by CMS. Year 2015): Coinciding with the development of an initial Reporting Set, CMS should • Measures should be phased in, beginning complete development of a standardized with a limited number of measures to reporting infrastructure. This mechanism guarantee that reporting is manageable for should provide a standard method for states providers, plans, and states. Over time, the to report to CMS; an infrastructure to collect, number of measures will increase to ensure house, and analyze data; and the ability of the that the reporting set is comprehensive. The public to compare results. common reporting sets of measures are not intended to supersede or reduce the level of Federal Incentives to Report (Target Date: current reporting. Federal Fiscal Year 2016): No later than one • To the extent possible, measures should be year after the development of an initial appropriately risk-adjusted to take into Reporting Set, states would begin to receive account severity of illness and social financial incentives through the Medicaid determinants of health that may account for program for reporting on applicable different baselines for different populations measures. These incentives would take into and sub-populations (e.g., education level, account the cost of implementing a language barriers, food security, comprehensive measurement system at the income/poverty level, etc.). state, plan, and provider level. Measure • Data should be stratified to reflect reporting must be accompanied by timely reporting for fee-for-service providers and feedback reports to providers to inform their managed care; diverse Medicaid populations practice. (i.e., children, pregnant women, adults, blind, and disabled); state eligibility levels; and Mandatory Reporting by All States (Target duration of enrollment. To minimize Date: Federal Fiscal Year 2017): No sooner reporting burdens, when possible, measures than one year after the introduction of should be drawn from those that have already financial incentives for reporting, CMS should been established, such as measures endorsed require all states to report on all applicable by the National Quality Forum (NQF), and use measures. currently available data to the extent possible. It is essential that the common Information gleaned from comprehensive reporting set evolve over time to address mandatory reporting would be available for gaps in measurement. Congress to make informed, evidence-based • To the extent possible, and recognizing the decisions about how to provide financial and varying subpopulations that different health programmatic incentives to states to improve care programs address, Medicaid quality their Medicaid program based on quality, measures should be harmonized with those of patient experience, and access to care. other programs. • Development of the common reporting sets should entail broad stakeholder input.

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III. Areas for Additional Consideration options. To capture the quality of care provided to populations across payers, it will Healthier Individuals and Communities— be vital to work toward standardized Social Determinants of Health: processes to measure quality and system- The Partnership for Medicaid recognizes that wide improvements. With the goal of the health of an individual does not depend assisting all individuals to receive high- on medicine and health care alone. Many quality health care, the members of the factors from outside the walls of a medical Partnership for Medicaid stand ready to facility—and outside the scope of access to participate in such an effort. traditional health care services—affect an individual’s health, such as housing, poverty, Program Improvement Can Be Achieved education, nutrition, and even the urban Through a Variety of Mechanisms: environment. In fact, much of life expectancy Quality measurement is not an end unto itself. and health status can be attributed to social Rather, quality is measured so that program determinants of health: 40 percent to social managers, policymakers, and stakeholders and economic factors, 30 percent to health can identify areas where services are behaviors, and 10 percent to the physical delivered effectively and efficiently, as well as environment, leaving just 20 percent to areas for improvement. This information can clinical care.10 Although this proposal focuses also be used in ways beyond payment reform, on health care quality, comprehensive such as the highlighting of best practices and approaches to achieve the aims of the the scaling up of these best practices for National Quality Strategy will be needed to larger audiences. The members of the address population health. Partnership for Medicaid expect that such changes will occur as a result of the actions Health Care Quality Is a Person-Centric Issue: proposed here and look forward to working This proposal is designed to assist all with other stakeholders on these efforts. stakeholders in understanding and improving

the quality of care provided to Medicaid

beneficiaries. But the Medicaid program

operates within, and is significantly

influenced by, the health care system at large. Moreover, many beneficiaries are often disenrolled and reenrolled into the program due to changes in income or bureaucratic issues. This situation leads to churning between Medicaid and other coverage

10 Booske, B., Athens, J., Kindig, D., Park, H., and Remington, P. Different perspectives for assigning weights to determinants of health. County Health Rankings Working Paper. http://www.countyhealthrankings.org/sites/default/ files/differentPerspectivesForAssigningWeightsToDe terminantsOfHealth.pdf. Accessed 21 November 2013.

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APPENDIX: Existing Quality Activities Conducted by Medicaid Providers and Plans

While Medicaid lacks a standardized federal reporting strategy, safety net providers have done substantial work to promote quality improvement. But these efforts have been largely uncoordinated and vary among providers, health plans, and the patient populations within Medicaid.

The following efforts, listed by provider type or program, provide a foundation for a coordinated, national reporting strategy.

Existing State or Existing Federal Medicaid Medicaid Population Private-Payer Quality Provider Type Quality Measurement Opportunities and Challenges Served Measurement Reporting Reporting Requirements Requirements

Acute Care More than 3,400 acute Few federal-level reporting • Hospitals must report CMS • While there is not yet robust national Hospitals care hospitals nationwide requirements for Medicaid: Core Set quality measures to quality reporting in Medicaid, the serve Medicaid patients • No federal payments to states the state. Medicare program requires hospitals in varying numbers, for provider-preventable • In a handful of states, to report on a multitude of measures, including hospitals that conditions, most of which apply hospitals participating in many of which are very similar to serve a safety net role by to hospitals. Medicaid delivery system Medicaid quality initiatives. This caring for a • Voluntary state reporting to transformation waivers also mandatory reporting includes disproportionate share of CMS on CMS Core Set quality have to report quality-related measures for Hospital Compare. Medicaid beneficiaries. measures for Medicaid-eligible measurement data to the state • Increasingly, Medicare quality adults; hospital reporting to the and to CMS. reporting includes all patients—not state is mandatory. only Medicare beneficiaries.

Community CMHCs and other related No Medicaid-focused federal • Some CMHCs participate in Multiple voluntary quality Mental Health organizations serve over reporting requirements. Medicaid Managed Care and improvement programs, including: 8 million low-income report quality measures to the • NCQA Patient-Centered Specialty Centers children and adults with MCO as part of the MCO’s Practice Recognition Program (CMHCs) serious mental health broader quality reporting • The Substance Abuse and Mental and addiction disorders. requirements. Health Services Administration (SAMHSA)–Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions (CIHS) • National Council for Behavioral Health.

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Dental There is little available No federal reporting • Dental Quality Alliance • At this time, there are no adult Providers information about dental requirements, but quality (DQA) has developed and quality measures around dental care, care for adult Medicaid measures for pediatric oral health endorsed a set of pediatric oral but the DQA is developing adult beneficiaries, as it is not a care have been developed. health measures. The performance measures. provided benefit in most measures apply across public states. Dental benefits are and private programs; align required for children in with current CMS oral health Medicaid and CHIP; a strategy; and were tested for 2008 CMS study found feasibility, validity, reliability, that 38 percent of eligible and usability based on the children received a CHIPRA measure criteria and dental visit that year. that of the National Quality Forum. • AHRQ has developed an adult dental survey for CAHPS that focuses on patient satisfaction.

Family Health Family health providers Few federal reporting • The American Board of • Tremendous opportunity exists in Providers serve diverse groups of requirements: Family Medicine requires the Patient-Centered Medical Home Medicaid-eligible • Initial Core Set of Adult Health certified Family Physicians to and Accountable Care Organization individuals, including Care Quality Measures for complete Maintenance of practice models being demonstrated in disabled and low-income Medicaid-Eligible Adults: state Certification courses in a many states via implementation grants non-disabled adults, reporting to CMS is voluntary variety of areas, including and pilot projects. These physician-led children, the elderly, and and, to the extent adopted, may Performance in Practice care models improve quality of care, pregnant women. On result in state-specific mandatory Modules, which are web- while lowering costs by incorporating average, 15% of family provider reporting. based, quality improvement each patient into a care team where physician's patients are • CHIPRA Quality of Care and modules in different health their health is addressed by team. Medicaid recipients; in Performance Measurement areas. Through these modules, • Sixty four percent of the American non-metropolitan areas, Initial Core Set of Children's quality indicators for Academy of Family Physicians’ that number jumps to Health Care Quality Measures: individual physician practice membership accepts new Medicaid 19%. state reporting to CMS is are assessed and the physician patients in their practices, and this completes a quality

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voluntary and, to the extent improvement plan for their number is expected to grow with the adopted, may result in state- practice by using their own implementation of Section 1202 of the specific mandatory provider performance data indicators. Affordable Care Act, otherwise known reporting. • Providers who contract with as the Medicaid Medicare Primary Care • Clinical Quality Measure (CQM) Medicaid MCOs report quality Parity Payment. The provision reporting associated with the measures to the MCO as part of provides for higher payment in both EHR Meaningful Use Incentive the MCO’s broader quality fee-for-service and managed care Program. reporting requirements. settings for specific primary care services furnished by physicians who meet certain eligibility criteria.

Federally FQHCs serve 1 in 7 Comprehensive federal-level • 80% of FQHCs participate in • Lack of standardized and aligned Qualified Medicaid beneficiaries reporting requirements related to Patient-Centered Medical quality metrics across domains (MU, nationwide. Of the over health center operations, not Home (PCMH) transformation PCMH, HEDIS, UDS, state based Health 22 million patients health Medicaid specific: initiatives, including the CMS metrics). Centers centers serve, 40% • Federally funded FQHCs are Advanced Primary Care • Data currently exists in silos (clinical, (FQHCs) (approximately 8.8 required to report clinical quality Demonstration, the Safety Net financial, administrative, payer, etc.); million) are covered by performance measures annually Medical Home Initiative significant investments in Medicaid/CHIP. through the Uniform Data System sponsored by Commonwealth infrastructure, skilled technical (UDS). Health centers currently Fund, and PCMH recognition resources, and improved partnership report clinical outcome data to and accreditation and report among all key players and State HRSA on 15 measures. requisite quality measures. Medicaid agencies are needed in order • UDS is maintained by HRSA, and • Most FQHCs have experience to interpret, analyze and utilize the measures reflect HRSA priorities; reporting clinical measures data. many measures are similar to and quality metrics to private • Additionally, research is needed to measures from NQF, NCQA, etc. payers and within state-based document the circumstances under • Health centers receiving initiatives, but very little data which providers achieve high Medicaid EHR Incentive is available. performance in cost savings, quality, Payments also report Meaningful and patient experience measures. Use (MU) Clinical Quality Measures (CQMs) associated with the CMS Medicaid EHR Incentive Program.

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Existing State or Medicaid Existing Federal Medicaid Quality Private-Payer Quality Opportunities and Provider Type Population Served Measurement Reporting Requirements Measurement Reporting Challenges Requirements

Long-Term Medicaid is the primary In LTSS and Medicaid, there are both provider- • A number of states have • Medicaid-covered LTSS Services and payer for long-term based and population-based quality measures. public reporting programs provides services to a broad services and supports Federal requirements include: for certain provider types range of people with varying Supports (LTSS). These services • CMS computes and publicly reports quality (e.g., nursing centers, home health care needs in a (LTSS) are delivered in both measures from data Medicare- and Medicaid- health) that are not tied to number of different settings. institutional and home certified nursing centers routinely collect. payment, and generally • LTSS quality efforts and community-based • CMS requires Medicare-certified home health focus on structure or currently underway in settings and cover agencies to collect and transmit performance process quality measures. Medicaid often differ from services such as data for all adult patients whose care is • Among states that collect state to state. nursing center and reimbursed by Medicare and Medicaid with the quality measures for nursing • There are a variety of home health care, as exception of patients only receiving pre- or centers that are tied to efforts underway to try to well as a variety of postnatal services. payment, they tend to focus pay for quality through others at the state’s • Medicaid-financed Home and Community- on staffing, survey value-based purchasing option or through Based Services (HCBS) quality measures are outcomes, patient arrangements, as well as waivers. included in Section 1915(c) waivers and satisfaction, and clinical quality initiatives that have These services and implemented on a state-by-state and program- quality measures. been undertaken by supports are available by-program basis. professional associations. to people who lack the • Under the duals demonstrations, contracts capacity for self-care with managed care plans focus primarily on due to a physical, population based quality measures, including cognitive, or mental HEDIS, rather than provider based quality disability or condition, measures. CMS requires MCOs in the which can result in the demonstrations, and thus the LTSS providers need for hands-on with whom they contract, to meet reporting assistance or requirements applicable to Medicare Special supervision over an Needs Plans (SNPs) in addition to state extended period of requirements and reporting on LTSS. The time. National Quality Forum Measurement Advisory Panel has developed measures relevant to the demonstrations.

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Existing State or Existing Federal Medicaid Medicaid Private-Payer Quality Opportunities and Provider Type Quality Measurement Reporting Population Served Measurement Reporting Challenges Requirements Requirements

Medicaid Capitated Medicaid Significant federal-level reporting States set reporting requirements, • Although Medicaid MCOs all Managed Care MCOs serve 29.1 requirements: often using nationally established must undertake quality million Medicaid • Federal law requires various quality quality measures, including: assurance activities, results Organizations enrollees—more than monitoring and improvement • Healthcare Effectiveness Data and often cannot be compared half of the 57 million processes for capitated Medicaid Information Set (HEDIS) measures, among states. individuals enrolled in managed care. which assesses effectiveness, access • While there are significant the Medicaid program • Quality assurance and improvement and availability, and experience of quality measurement and in 2011. strategy must include standards such care, as well as utilization and improvement requirements for as continuity and access as well as relative resource use. Medicaid Managed Care Plans, procedures to monitor quality and • Consumer Assessment of Health almost half of Medicaid appropriateness of care. Providers and Systems (CAHPS) enrollees are served by primary • Enhanced federal funding is measures, which assess patient care case management (PCCM) available for external quality review experience and satisfaction. or fee-for-service (FFS) organizations that conduct • Some states require MCOs to be arrangements, for which no independent reviews of MCO accredited by NCQA. comparable federal activities. • Some states publish a health plan requirements for quality report card. monitoring or improvement exist.

Obstetric and Medicaid provides Few federal reporting requirements: • Providers who contract with • Maternity and perinatal Women’s services to 22.4 million • CHIPRA and the Affordable Care Act Medicaid MCOs report quality quality collaboratives, which women, covers 45 (ACA) established an initial core set of measures to the MCO as part of the bring local ob-gyns, providers Health percent of births, and is children’s and adult health care MCO’s broader quality reporting specializing in women's health, Providers the largest financer of quality measures for voluntary state requirements. and other stakeholders publicly funded family reporting to CMS, which include together to accelerate adoption planning services. measures for obstetric, gynecologic, of best practices, have and primary care. To the extent that demonstrated improvements to states adopt measure reporting, may maternal and newborn result in state-specific mandatory outcomes and reductions in provider reporting. health care costs.

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Pediatric • More than one-third Few federal reporting requirements: • The American Board of Pediatrics • Given the historic focus on Providers of all children in the • The Children's Health Insurance (ABP) Maintenance of Certification Medicare, there is a relative United States—and Program Reauthorization Act requires pediatricians to participate lack of quality measures for two-thirds of children (CHIPRA) established a core set of in a range of ABP-approved quality children—especially those with with medical children’s health care quality improvement projects to assess and special health care needs and complexities—are measures: state reporting to CMS is improve the quality of pediatric medical complexity—as well as covered by Medicaid. voluntary and, to the extent adopted, care. children requiring inpatient • On average, 30 may result in state-specific mandatory • For nurse practitioners, the care. The Pediatric Quality percent of a provider reporting. Quality and Safety Education for Measure Program has begun to pediatrician’s patients • CHIPRA also disseminated best Nurses (QSEN) program offers an address this gap, but there is a are covered by practices in measurement and opportunity to ensure that need to sustain funding for Medicaid. reporting, established the Pediatric evidence-based practice and quality pediatric quality. Pediatric • Pediatricians provide Quality Measures Program, improvement expertise is part of providers are working to two-thirds of all office authorized demonstration projects, pediatric nurse practitioner reauthorize the CHIPRA quality visits for children on and created the children’s EHR programs and continuing education provisions. Medicaid, often in format. requirements. • The pediatric medical home multidisciplinary • One of the 24 measures of the initial • Children’s hospitals that are model has been associated with teams. core set focuses on children’s hospital accredited by the Joint Commission better health outcomes and • Although they care quality; remaining measures report on ORYX measures. patient satisfaction. account for less than 5 focus on prevention and primary care. Additionally, as with acute care percent of hospitals, hospitals, reporting and non- children’s hospitals payment for potentially preventable provide 47 percent of conditions in the Medicaid program the hospital care apply to children’s hospitals, and required by children children’s hospitals and eligible covered by Medicaid. providers report on clinical quality measures for EHR meaningful use.

THE NEXT STEP: IMPROVING QUALITY AND REDUCING COST APPENDIX

Acronyms and Definitions

ACA: Affordable Care Act Hospital Compare: A consumer-oriented AHRQ: Agency for Healthcare Research and website maintained by CMS that provides Quality information on how well hospitals provide CAHPS: Consumer Assessment of Healthcare recommended care to their patients Providers and Systems, a comprehensive HRSA: Health Resources and Services and evolving family of surveys that ask Administration consumers and patients to evaluate the Initial Core Set Quality Measures: A set of interpersonal aspects of health care quality measures for voluntary use in CHIP: Children’s Health Insurance Program, a Medicaid and CHIP programs developed program that provides health coverage to and maintained by CMS and AHRQ; the children in families with incomes too high pediatric set was established by CHIPRA to qualify for Medicaid but who can’t while the adult set was established by the afford private coverage Affordable Care Act CHIPRA: Children’s Health Insurance LTSS: Long-Term Services and Supports, Program Reauthorization Act, which which includes both institutional care and among other things established the initial home and community based services core measure set of children’s health care MCO: Managed Care Organization quality measures MU: Meaningful Use, the set of standards CIHS: Center for Integrated Health Solutions, defined by the CMS Incentive Programs a joint initiative of the Substance Abuse that governs the use of electronic health and Mental Health Services Administration records and allows eligible providers and (SAMHSA) and the Health Resources and hospitals to earn incentive payments by Services Administration (HRSA) meeting specific criteria CMHC: Community Mental Health Center NCQA: National Committee for Quality CMS: Centers for Medicare & Medicaid Assurance Services NQF: National Quality Forum CQM: Clinical Quality Measure, a set of ORYX: The Joint Commission’s national measures of which reporting is required hospital quality measures which are for meaningful use for the Medicare and publicly reported Medicaid Electronic Health Record (EHR) PCCM: Primary Care Case Management Incentive Programs PCMH: Patient Centered Medical Home DQA: Dental Quality Alliance SAMHSA: Substance Abuse and Mental EHR: Electronic Health Record Health Services Administration FFS: Fee for Service SNP: Special Needs Plan, a type of Medicare FQHC: Federally Qualified Health Center Advantage Plan for individuals with HCBS: Home and Community-Based Services specific diseases or characteristics HEDIS: Healthcare Effectiveness Data and UDS: The Uniform Data System, a core set of Information Set, a set of performance and information appropriate for reviewing the quality measures developed and operation and performance of health maintained by the National Committee for centers Quality Assurance (NCQA)

THE NEXT STEP: IMPROVING QUALITY AND REDUCING COST DEFINITIONS

About the Partnership for Medicaid The Partnership for Medicaid is a nonpartisan, nationwide coalition made up of 23 organizations representing doctors, health care providers, safety net health plans, counties and labor. The goal of the coalition is to preserve and improve the Medicaid program.

While this proposal represents the collective views of the Partnership as a coalition, it has not been officially endorsed by each constituent Partnership organization.

The Partnership for Medicaid AFL-CIO America’s Essential Hospitals American Academy of Family Physicians American Academy of Pediatrics American Congress of Obstetricians and Gynecologists American Dental Association American Dental Education Association American Health Care Association Association for Community Affiliated Plans Association of Clinicians for the Underserved Catholic Health Association of the United States Children's Hospital Association Easter Seals The Jewish Federations of North America Medicaid Health Plans of America National Association of Community Health Centers National Association of Counties National Association of Pediatric Nurse Practitioners National Association of Rural Health Clinics National Council for Behavioral Health National Health Care for the Homeless Council National Hispanic Medical Association National Rural Health Association

THE NEXT STEP: IMPROVING QUALITY AND REDUCING COST