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.
Children and adult quality measures
The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA, P.L. 111-3) required the Centers for Medicare & Medicaid Services to develop a core set of children’s health care quality measures in Medicaid and CHIP (§1139A of the Social Security Act). The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) further 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.
The children’s quality measure set, developed in 2009, includes duration and stability of coverage measures, preventive care measures and measures for patients with special health needs. 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.
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 measures include, but are not limited to, process measures for receipt of screenings and vaccinations; outcomes measures for a variety of readmissions—for example, diabetes complications or congestive heart failure; and measures of patients’ experience of care.
Click here for the core set of adult health care quality measures for Medicaid.
Click here for the core set of child health care quality measures for Medicaid.