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A CHIPRA Quality Demonstration Grantee's Perspective on the Child Core Measure Set and Quality Measurement

      The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) grant builds on quality measurement activities initiated by creating an Enterprise Data Warehouse (EDW) in 2000. The EDW is the analytics platform for performance measurement used for quality improvement in Illinois. In 2002, Illinois programmed a single Healthcare Effectiveness Data and Information Set (HEDIS) measure and soon added HEDIS and state-defined measures providing the foundation for later reporting the CHIPRA core set. Quality measures, including the CHIPRA core set, are used as follows:
      • Medicaid population (state, substate, or program level), health plan (eg, managed care organizations, care coordination entities, managed care community networks), and provider-level reporting.
      • Pay for performance.
      • Public reporting.
      • Program evaluation/contract monitoring.
      • Benchmarking.
      • Informing policy.
      • Quality improvement.
      • Promoting practice/system change.
      • Reinforcing guidelines, evidence, and policy.
      The CHIPRA grant contributes to improved integrity of quality measurement in Illinois. The Department of Healthcare and Family Services convened a Quality of Care Measures Committee, bringing together measure implementers, programmers, and testers from various program areas. This committee addressed data quality, reporting, and administrative processes. Committee work resulted in programming and reporting efficiencies, shared responsibility, quality measure alignment, rigorous testing, and standardized reporting.
      The CHIPRA grant also improved public reporting. Illinois first publicly reported 20 CHIPRA core measures in 2013. That report serves as a template for future public reporting of other quality measures, thereby promoting transparency and accountability.
      By legislative mandate, Illinois Medicaid's primarily fee-for-service health care system will become predominately managed care by 2015. In January 2014, Illinois expanded Medicaid coverage under the Affordable Care Act. Care for existing and new populations will be provided through various managed care and care coordination models. To manage the proliferation of measures arising from multiple models and populations served, Illinois seeks alignment of quality measurement among entities serving children by using selected CHIPRA core measures to assess quality, and harmonization among existing measures reported by health plans by using nationally endorsed measures rather than state-defined measures. The outcome will be a coordinated system whereby quality is assessed using standardized metrics across organizations providing care.
      At the state level, future enhancements include improving analysis and reporting to more easily “consume” the data. Reports now include trend data stratified by delivery system, geography, and care entity. Plans include applying statistical analyses and using benchmarks. Through CHIPRA, Florida, Illinois, and Health Management Associates, a project partner, created a performance matrix displaying HEDIS benchmarks and trends with tests of significance. The matrix synthesizes complex data tables into a single pictorial representation of performance. Plans are to use the matrix to identify areas for quality improvement in Illinois and Florida. One area where academic institutions could help states is developing methods to synthesize measure results and use stratification to identify areas for quality improvement.
      On the national level, future benefits of quality measurement include more performance benchmarking among state Medicaid agencies. The CHIPRA legislation calls on the secretary of the US Department of Health and Human Services to identify and publish an initial core measures set to “facilitate comparative analyses across various dimensions of pediatric health care quality.” These measures will be used to “move toward a national system for quality measurement, reporting, and improvement.”

      Centers for Medicare and Medicaid Services; Center for Medicaid and CHIP Services. Core set of children’s health care quality measures for Medicaid and CHIP (child core set): technical specifications and resource manual for federal fiscal year 2013 reporting. May 2013. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-and-CHIP-Child-Core-Set-Manual.pdf.

      The secretary's report includes benchmarks of aggregate state performance on frequently reported measures.

      Department of Health and Human Services. 2012 annual report on the quality of care for children in Medicaid and CHIP. December 2012. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2012-Ann-Sec-Rept.pdf.

      The secretary's report could benchmark all core measures in the aggregate and provide state-specific information so states can gauge their performance relative to other states. The secretary's report could drive quality improvement by benchmarking more measures, as well as by supporting national learning opportunities for performance measurement and quality improvement.
      To realize these benefits, Illinois' commitment to measurement and quality improvement must be maintained even when faced with challenges. Limited financial and staff resources affect capacity. Measures require ongoing maintenance, data collection, programming, and IT infrastructure. The confluence of reporting child and adult core sets, and new core measures strains limited resources. Survey-based measures are costly, especially sampling in a complex health care delivery system. Using electronic health record (EHR) data to assess outcomes is a challenge for states like Illinois that do not yet have the means to obtain and warehouse electronic data.
      Even with these challenges, we encourage development of aspirational measures, including those collected using EHR data. These measures help frame the conversation among states, academic institutions, EHR vendors, and others regarding needed data and their use; they also help to grow our nascent use of EHRs. The challenge is, although our ability to collect discrete data is increasing through EHR adoption, our ability to aggregate it at a state level to assess Medicaid-population health may be diminishing. Currently our data are housed in a centralized repository, with most collected through fee-for-service claims. In our changing health care system, more encounter data will be collected, and data will come from other sources, including EHRs/exchanges and registries. Our challenge is how to gather and store complete, timely, Medicaid population–based data to assess performance and quality.
      Illinois is endeavoring to become more self-sufficient with its capabilities to analyze data and research health issues affecting our Medicaid population. Academic institutions could work with states to solve issues regarding fragmented data, data collection and aggregation, and data mining to detect emergent patterns of health care utilization, cost, and quality. When states and academic institutions partner to achieve shared goals, there is an opportunity to produce mutually beneficial and valuable work.
      The challenges in Illinois are outweighed by the benefits of a robust data analytics, measurement, and reporting system. Illinois is consolidating, standardizing, and aligning measures and seeking ways to collect and use EHR data. Illinois is committed to these efforts, and it supports measurement and innovation as essential strategies in the state's health care system to improve quality, improve population health, and reduce cost.

      Acknowledgments

      Funding for this project was received through grant CFDA93.767 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services . Illinois' Department of Healthcare and Family Services , the state's Medicaid agency, partnering with Florida, received a CHIPRA Child Health Quality demonstration grant in 2010. Through this grant, Illinois participates in the Pediatric Quality Measure Program (PQMP), providing a state perspective on quality measurement.

      References

      1. Centers for Medicare and Medicaid Services; Center for Medicaid and CHIP Services. Core set of children’s health care quality measures for Medicaid and CHIP (child core set): technical specifications and resource manual for federal fiscal year 2013 reporting. May 2013. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-and-CHIP-Child-Core-Set-Manual.pdf.

      2. Department of Health and Human Services. 2012 annual report on the quality of care for children in Medicaid and CHIP. December 2012. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2012-Ann-Sec-Rept.pdf.