The increased emphasis on quality as part of the Affordable Care Act (ACA) extends to Medicaid, and nearly every state is implementing delivery system transformations. In 2015 alone, 27 states introduced or expanded such efforts, including patient-centered medical homes, accountable care organizations, and risk-based managed care. States choosing to expand the role of Medicaid managed care to cover new populations and/or services are requiring plans to achieve goals for access, quality, and cost.

A new white paper from the Anthem Public Policy Institute – The ‘Nuts and Bolts’ Behind Quality Measurement in Medicaid Managed Care” explores the state of quality measurement in Medicaid managed care at this critical juncture, including some key challenges Medicaid programs face when it comes to measuring quality in managed care plans.

Why is quality measurement important for Medicaid?

Expectations are high that healthcare reforms such as value-based payments and medical homes will improve quality of care and health outcomes while moderating healthcare spending. In Medicaid, the emphasis on quality is especially important in states that have increased enrollment, or included a more diverse set of beneficiaries and/or services, in managed care. Quality measurement is essential for determining whether these expansions have resulted in improved member experience and outcomes.

While historically states have designed their own quality measurement and reporting strategies, CMS has finalized new requirements that will create national standards for measuring the quality of Medicaid managed care plans. Payers, providers, and quality measurement organizations also are shaping quality measurement strategies by convening multiple workgroups, developing recommendations for new measure sets, and testing new measures in select states’ Medicaid programs. As stakeholders continue their work to improve quality measurement in Medicaid managed care, a look at the current system highlights some key considerations:

  • Measures that assess whether individuals got the right care (“process measures”)—long used to assess quality—are weaker alternatives to measuring the real goal: to what extent did individuals’ health and quality of life improve? Simply receiving care does not guarantee good outcomes or improved health status.1
  • Measure developers should pay particular attention to populations and services not historically represented by quality measures (e.g., individuals with behavioral health conditions, individuals with intellectual and/or developmental disabilities, and managed long-term services and supports).
  • Quality measures should be well-tested, evidence-based, and peer-reviewed.
  • Despite a slow take-up to date, electronic medical records can be a useful source for tracking outcomes, identifying gaps in care, and developing quality improvement initiatives.

How do payers, providers and consumers use quality measurement?

Managed care expansions and delivery system transformations are the most recent motivators for a heightened focus on quality measurement in Medicaid, but they are not the only ones. For years, payers, providers and consumers (both in the private and public sectors) sought better information on the quality of care that individuals receive. All stakeholders have incentives to enhance quality measurement in Medicaid:

  • Payers: State Medicaid programs, as well as Medicaid managed care plans, use quality measures to monitor the outcomes of their investments to promote high quality, cost-effective services that improve the health of enrollees. Additionally, quality measurement is an essential component for linking payment to outcomes, such as through pay-for-performance programs or other value-based payment approaches.
  • Providers: Healthcare providers use quality measures to help assess whether their patients are healthier as a result of changes at the front-line of care. These changes include both payer-driven changes and professionally driven advancements.
  • Consumers: Medicaid beneficiaries are increasingly encouraged to use quality information when selecting a health plan or provider, and will likely become more important in consumers’ decision making as more information is available.

Learn more about Medicaid quality measurement by reading the other two papers in this series: