Although challenges persist, Medicaid has been instrumental to enabling access to care for the nation’s most vulnerable individuals: low-income pregnant women and children, people with disabilities, and low-income elderly Americans. In the past several years, Medicaid has covered millions more low-income nonelderly adults who otherwise could not afford insurance through the Affordable Care Act.
The organization and delivery of care to Medicaid beneficiaries has evolved with the program’s growth, often resulting in innovative approaches born from the need to do more with less.
For example, state Medicaid programs were early adopters of primary care medical homes (PCMHs). According to a July 2015 Health Affairs article, between 1996 and 2012, 25 states created PCMHs and other new delivery and payment models to support better communication with patients, team-based approaches to care, and treatment protocols tailored to specific at-risk patient populations. In many states, managed care has provided a means both to control costs and incent better care. By 2002, 58 percent of Medicaid patients were in some kind of managed care plan, and that number is expected to grow to 76 percent by 2016. And, a number of states are testing new models of more highly integrated models of care, especially for beneficiaries with more complex needs, such as those requiring long-term care or those dually eligible for Medicaid and Medicare.
In the past 20 years, Medicaid also has helped to greatly increase beneficiaries’ access to home and community-based services and supports, providing alternatives to institutional care and enabling disabled children to live at home, working age adults to live independently, and many older Americans to age in place.
States working with Medicaid managed care plans are gaining experience in reporting performance measures and linking them to reimbursement incentives to drive improvement, but standardizing quality measurement across state programs is a nascent effort.
The Centers for Medicare & Medicaid Services (CMS) adopted a core set of children’s healthcare quality measures, known as the Child Core Set, in 2009, and published an initial core set of adult health care quality measures, the Adult Core Set, in 2012. NQF’s Measure Applications Partnership (MAP) provides guidance to the U.S. Department of Health and Human Services on these measure sets, as well as measures to assess the quality of care for Americans who are eligible for both Medicaid and Medicare.
Forty-one states reported children’s measures for both Medicaid and CHIP in 2013, up from 34 in 2011, and the number of measures reported by states increased from a median of 12 to 16. According to the 2014 Annual Report on the Quality of Care for Children in Medicaid and CHIP, states continue to perform highly on the children’s primary care measure (i.e., percent with a visit to a primary care physician), but improvement is needed in areas such as preventive care for young children and adolescents and coordination of care for children with mental or behavioral health needs.
Meanwhile, states began reporting on the Medicaid Adult Core Set in 2013, with 30 states reporting a median of 16.5 measures. Measures reported most frequently focused on diabetes care management, women’s preventive health, postpartum care visits, and mental health treatment.
“An important goal of NQF’s work on behalf of the Medicaid program is to help foster reporting of a core set of measures across states,” said NQF President and CEO Christine K. Cassel, MD. “In doing so, we will strengthen the ability to compare measure results across states and have more robust benchmarks while reducing measurement burden.”
MAP recently released its latest recommendations to HHS for updating both the Adult and Child Core Sets to address high-priority areas such as behavioral, reproductive, and maternal health. MAP also shared guidance on improving care for dual-eligible individuals.
For more information, contact measureapplications@qualityforum.org.