Quality care is generally considered to be that which is safe, effective, patient-centered, timely, equitable, and reliable (IOM 2001). At the system level, quality improvement efforts should focus on receipt of the right care, at the right time, in the right setting, all the time (HHS 2011). Ultimately care should be provided that leads to the best outcomes for patients—improvement in health, maintenance of function, and for patients who are in declining health, appropriate and effective care and supportive services that improve quality of life.
Medicaid and CHIP programs engage in quality improvement through delivery system design, payment incentives, and holding plans and providers accountable for desired quality and cost outcomes. States are increasingly incorporating quality measures into their payment and purchasing strategies. They set quality standards in managed care contracts and create incentives for plans to meet targets for improvements in the process and outcome of care, and in the patient experience.
Child quality measures
The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA, P.L. 111-3) required the Centers for Medicare & Medicaid Services (CMS) to develop a core set of children’s health care quality measures in Medicaid and CHIP (§ 1139A of the Social Security Act). The children’s quality measure set, developed in 2009, includes measures related to primary and preventive care, maternal and perinatal health, care of acute and chronic conditions, dental care and oral health, behavioral health care, and patients’ experiences of care. CMS is required to report to Congress every three years on the status of voluntary reporting on the core quality measures and on other efforts to advance quality of care in Medicaid and CHIP.
The Bipartisan Budget Act of 2018 (P.L. 115-123) requires states to report on the child core set for Medicaid and CHIP beginning with reports for fiscal year (FY) 2024.
Click here for the core set of child health care quality measures for Medicaid.
Adult quality measures
The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) required the development of a core set of adult health care quality measures in Medicaid (§ 1139B of the Social Security Act) for voluntary use by states, managed care organizations, and providers. CMS and the Agency for Health Care Research and Quality (AHRQ) developed the core set of adult quality measures in 2011, and voluntary reporting of these measures began in 2014. The adult core set includes measures related to primary and preventive care, maternal and perinatal health, care of acute and chronic conditions, behavioral health care, and patients’ experience of care.
The SUPPORT for Patients and Communities Act (P.L. 115-271) requires that states report behavioral health measures in the adult core set beginning with reports for FY 2024. Moreover, states with Section 1115 research and demonstration substance use disorder (SUD) waivers may be required to report performance measures to utilization of SUD treatment services and other SUD-related services.
Click here for the core set of adult health care quality measures for Medicaid.