Program objectives
CMS encourages all States to voluntarily report the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (the Child Core Set) each year.5 As part of the demonstration, 10 States implemented projects involving the Child Core Set or similar quality measures.6 Guided by CMS’s original grant solicitation, the projects implemented by these States aimed to: (1) enhance technical capacities for accurately reporting the core measures to CMS, and (2) develop strategies for using the core measures to improve quality of care at the State, health system, or practice level.
State strategies
To accomplish their objectives, the 10 demonstration States used varying combinations of the following strategies:
- Hiring dedicated computer programmers to develop the technical procedures needed to calculate the measures using CMS specifications.
- Developing new procedures to assemble data files from diverse sources and checking them for accuracy.
- Collecting the patient experience surveys needed to calculate certain measures.
- Establishing statewide groups to provide technical oversight and policy direction for using measures to track performance.
- Developing reports for policymakers, providers, and consumers to compare performance with national benchmarks.
- Identifying variation across practices, regions, or plans; and monitoring changes in performance over time.
- Supporting pay-for-reporting programs to encourage use of electronic health record (EHR) data for measurement.
Lessons learned
States can substantially improve their capacity to report quality measures for children by strategically enhancing technical resources and developing methods for linking data sets. Key stakeholders within States especially value measures that can be used for QI within health systems and practices. Most States have not yet demonstrated widespread use of EHR data for calculating quality measures.
Specifically, analysis of information from the projects implemented by the 10 demonstration States working in this area and from a survey of physicians fielded in several States yielded the following insights:
- Reporting capacity was influenced by a State’s Medicaid data availability, technical expertise (for example, the capacity to link State data systems together), past experience with quality measurement, availability of staff time, and demand for the measures. Both the availability of the demonstration funds and substantial technical assistance from CMS allowed States to overcome some of the challenges they faced and increase the number of measures reported to CMS.
- States can use validated quality measures for children to monitor quality and compare performance across health systems and managed care plans. Policy or programmatic changes, such as stipulating benchmarks in managed care contracts and developing incentives for improvement, can be used to increase performance specifically in relation to children’s health care.
- Access to fee-for-service claims data enables but does not guarantee that all administrative measures can be reported.
- Stakeholders value State reports on the performance of health plans and child-serving practices, especially when States integrate stakeholder input into report design and when States align measures across diverse reporting requirements.
- The majority of child-serving physicians receive quality reports and believe they are effective for QI, but only one-third actually use quality reports in their QI activities. Physicians in demonstration States used quality reports for QI at about the same rate as physicians in a similar state that did not have a demonstration grant.
- Lack of timely data makes it difficult for providers to use State-produced quality reports to assess efforts to improve quality. Practices need substantial technical assistance from EHR vendors and QI specialists to use their own EHR data to inform QI initiatives.
- States may not be able to produce measures that require EHR data because States and health systems have not yet developed the infrastructure needed to support data transfer from providers’ EHRs. Furthermore, incomplete or inconsistent documentation in EHRs and paper charts means that practices first have to improve documentation before they can improve measure reporting.
| Maine increased the number of Child Core Set measures it reported to CMS from 14 in 2010 to 18 in 2014 through various strategies. For example, the State identified ways to use health information exchange (HIE) data to calculate measures and made other adjustments, such as adding a new billing code modifier to distinguish between global developmental and autism screenings. However, the State was unable to report on all 26 measures due to the limited availability of administrative data on behavioral health services and clinical data from practices’ EHRs. |
| Massachusetts conducted interviews with practices and focus groups with families to help them design useful quality measure reports. Report production was delayed because interpreting measure specifications and developing legal agreements to access needed data took longer than expected. The State reported that its efforts ultimately yielded robust and useful reports for practices, families, and policymakers on Medicaid, CHIP, and commercially insured patients. |
| North Carolina incorporated additional child-focused measures into quarterly reports that the State makes available to all practices serving Medicaid and CHIP beneficiaries. Practices indicated that the reports helped them assess their performance and identify QI priorities. However, given delays in claims processing and infrequent reporting periods, the reports were difficult for practices to use to assess whether redesigned workflows improved care. In response, State-hired practice facilitators helped practices run supplemental reports directly from their EHRs so they could track QI changes in real-time. |
