Research

New white paper series explores transformations in quality measurement, reporting for Medicaid managed care

Thursday, November 17, 2016
Summary and Key Findings: 

The Anthem Public Policy Institute recently released three white papers on the evolving state of quality measurement for Medicaid managed care organizations. These papers discuss issues of quality measurement in Medicaid managed care in extensive detail:

The 'Nuts and Bolts' Behind Quality Measurement in Medicaid Managed Care explores the present state of quality measurement in various state Medicaid programs and suggests several methods of improvement.

Balancing Standardization and State Flexibility in Medicaid Quality Measurement and Reporting addresses the two prevailing approaches in reforming quality measurement: standardizing measures for easier comparison across states or increasing state flexibility to promote innovation and focus on state priorities. Both have pros and cons, and this paper describes the trade-offs that are required when weighing one approach over the other.

The Impact of Medicaid Quality Rating Systems on Consumer, Health Plan and Provider Behavior provides insight into if and how quality measurement impacts consumers. This paper highlights the ability of Medicaid managed care ratings systems to empower patients to compare prospective health care plans and make informed enrollment decisions.

All three papers examine the complexity of quality measurement in Medicaid managed care and the implications of shifts in policy for providers, payers and most importantly, consumers.

Background on the Medicaid Regulations

In April of 2016, the Centers for Medicare & Medicaid Services (CMS) finalized new regulations that emphasize consistency in Medicaid quality measures across states and improve alignment between health care programs in those states—like Medicaid and state health insurance exchanges. Under these regulations, CMS expects to determine a core set of measures and corresponding methodology for all MCOs, as well as the structure and process of the overall quality rating system.  States will then have three years to develop and implement their quality ratings system (QRS). States will be able to use an alternative methodology or adopt additional measures for use in the rating system, as long as the rating system is substantially comparable to the overall framework developed by CMS and the state obtains CMS approval.

This regulation is particularly important for Medicaid beneficiaries enrolled in managed care organizations (MCOs). Enrollment in these programs has doubled in the past decade, as states expanded eligibility for Medicaid under the ACA, and extended managed care to a more diverse set of Medicaid beneficiaries.

MCOs are typically required to report on measures of access, quality and cost. With a growing managed care population, quality measurement and reporting have taken on greater importance. They are vital in revealing the quality of care that enrolled individuals receive, as well as determining, at the most basic level, whether the expansions in MCO enrollment have resulted in improved member experience for the new enrollees.  

Medicaid managed care plans differ greatly from state to state. Therefore, there is no one-size-fits-all approach to measurement. The result is that at present, the U.S. is a veritable patchwork of quality measures and reporting systems that range from comprehensive to the bare-minimum required by federal regulations in effect prior to April 2016. 

Considerations for the Future of Quality Measurement and Reporting

Over the next few years, CMS and states will be collaborating closely to develop quality rating systems that emphasize greater consistency in Medicaid quality measurement and reporting across states and greater alignment across government-sponsored health care programs. Payers, providers, and quality measurement organizations also are shaping quality measurement strategies by convening workgroups, developing recommendations for new measure sets, and testing new measures in select states’ Medicaid programs. As this work takes place, stakeholders should take into account several key considerations:

Quality measures should be well-tested, evidence-based, peer-reviewed, and focused on measuring the health outcomes of individuals – with particular attention to populations newly entering managed care such as individuals with behavioral health conditions, individuals with intellectual and/or developmental disabilities, and individuals enrolled in managed LTSS programs.

As CMS continues to develop a quality rating strategy, it should be mindful of the diverse needs of the populations served through Medicaid managed care. CMS should also take into account the work already done in many states to build successful quality strategies that offer tools and “best practices” to others. States should continue to serve as testing grounds for innovative quality measurement and reporting approaches.

As Medicaid managed care quality rating systems grow, it is imperative to assess on an ongoing basis whether and to what extent these systems are able to effectively drive changes in consumer, health plan and provider behavior. Additional work should focus on ensuring that consumer-facing quality ratings are comprehensible, relevant, and align with consumers’ other priorities and considerations related to health plan selection.

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