Janice M. S. Lopez, PharmD, MPH

The provision of high-quality healthcare is a priority for US health plans and the CMS. Health plans can implement quality initiatives to ensure appropriate healthcare for their beneficiaries and use quality measures in their various initiatives to assess quality of care and outcomes.

 We reviewed publicly reported diabetes quality measures for Medicaid fee-for-service (FFS) programs in all 50 states and the District of Columbia. Our objective was to provide insights into the extent of diabetes quality measure reporting (ie, which diabetes quality measures are being reported and what percentage of states are using the diabetes Healthcare Effectiveness Data and Information Set [HEDIS] measures) and into the quality of care being provided (ie, achievement of established goals in diabetes care and state-level performance on diabetes quality measures).

 Overall, the number of Medicaid FFS programs reporting these data was low: 23 states reported data on at least 1 HEDIS measure. The most common measures reported were process measures (eg, retinal eye exams and HbA1c testing); outcomes measures such as the proportion of patients achieving goal were much less frequently available. Few states had historical data available, which limits the opportunity for retrospective analyses or quality benchmarking.

 This research is important, as an understanding of the current landscape of quality measures for the Medicaid diabetes population is critical to designing and implementing initiatives aimed at improving the quality of care for individuals living with diabetes.

The provision of high-quality healthcare is a priority for the United States, in large part as a result of the Affordable Care Act (ACA) and its focus on 3 goals to improve the experience of care, improve the health of populations, and reduce the per capita costs of healthcare. These triple aims also guide the National Quality Strategy that was established as part of the ACA, which describes the national priorities and strategic plan for quality improvement in healthcare. 

This reformative health policy environment has spurred many organizations to call for methods to measure, track, and improve the provision of healthcare and engage in the nationwide conversation regarding the definition of “value.”

Medicaid is responsible for providing healthcare coverage to more than 72 million beneficiaries.

 The population served by Medicaid will continue to expand under the ACA. The CMS has been a major forerunner in implementing quality healthcare measures and has implemented ongoing initiatives to ensure quality healthcare for both Medicare and Medicaid beneficiaries through accountability and public disclosure.

The ACA required the implementation of a core set of healthcare quality measures for adults participating in Medicaid. The initial set of measures was released in 2013.

 Reporting by states is voluntary; however, many states now require Medicaid managed care plans to report quality measures using the Healthcare Effectiveness Data and Information Set (HEDIS) tool. Although Medicaid is shifting away from a traditional fee-for-service (FFS) model, a substantial number of complex beneficiaries remain within this structure (eg, those with multiple chronic conditions and high resource utilization) and account for a disproportionate amount of total Medicaid expenditures.

 As such, we sought to explore the availability and breadth of data from quality measurement programs that traditional FFS Medicaid plans and Medicaid managed care organizations (MCOs) have instituted for patients with diabetes.

Diabetes-related quality data were obtained as of July 2015 through a Web-based search of publicly reported data, such as state Medicaid and related websites (list of websites provided in Table 1). This research included a review of all 50 states’ Medicaid FFS programs, the District of Columbia, and the largest Medicaid MCO in the 10 states with the highest Medicaid enrollment through May 2015: California, New York, Texas, Florida, Illinois, Ohio, Pennsylvania, Michigan, Georgia, and New Jersey. For purposes of this research, a Medicaid MCO was defined as a contracted entity that administers Medicaid benefits on behalf of a state. Because of the inconsistencies observed in the degree and time frames with which Medicaid FFS plans reported their diabetes-related quality data on public websites, the investigators reached out personally to a 10% sample of states to validate the completeness of data that were captured after the initial Web-based research was completed. Medical and quality program directors at 5 state Medicaid FFS programs (California, New York, Florida, Ohio, and Michigan) were contacted via phone and/or e-mail by the research team. For each state, a director of policy and quality, or similar role, was sought to provide confirmation on the data. These 5 states were chosen for the sample because they include the greatest number of covered lives under their FFS models.

The extent of diabetes-related quality measures found included mostly HEDIS Comprehensive Diabetes Care indicators (both current and previous measures), such as:

Blood pressure (BP) control (<140/90 mmHg)

Low-density lipoprotein cholesterol (LDL-C) screening

Other non-HEDIS diabetes-related quality measures were also identified and documented when found. When provided, the percentage of Medicaid patients meeting each quality indicator in each program was captured. Quality data were analyzed by examining the states’ individually published information for trends in Medicaid program reporting and performance while also noting those Medicaid plans that did not report any data.

All 50 states and Washington, DC, reported using HEDIS as their quality reporting system for either Medicaid FFS or MCO patients. For FFS programs, publicly reported data on diabetes quality measures were poor, with only 23 states (45%) having published data on at least 1 HEDIS measure for their FFS Medicaid lives or total Medicaid lives (Figure 1). We also found that the data-reporting period (ie, the date of the data available on the websites) varied widely, from as early as 2002 through March 2015. Only 6 states reported data from the previous year (2014; Colorado, Illinois, Tennessee, Florida, Vermont, and Connecticut). Only Colorado, Florida, and Vermont reported 7 or more HEDIS diabetes quality measures. Other non-HEDIS diabetes measures identified included hospital admissions rate for short-term complications associated with diabetes, hospital admissions rate for long-term complications associated with diabetes, proportion of patients with microalbuminuria, proportion of patients receiving screening for microalbuminuria, proportion of patients classified as obese or overweight, receipt of influenza vaccine in adults aged 50 to 64 years, health literacy, tobacco use, and composite measure of HbA1c, low-density lipoprotein cholesterol (LDL-C), blood pressure, and tobacco use.

Of the 23 states with publicly reported data for the FFS programs, the most commonly reported process measure was “percentage of patients receiving HbA1c testing” (21 of 23 states), followed by the other screening measures: LDL-C screening (19 of 23 states) and eye examination (12 of 23 states). The least frequently reported measures were those that require states to conduct medical record reviews or additional data analysis (eg, outcome measures such as percentage of patients achieving HbA1c <7%, proportion of patients achieving BP control, and proportion of patients achieving LDL-C <100 mg/dL).

 Moreover, few states had published consecutive data year over year that would enable examination of changes in reporting following Medicaid expansion as a result of the ACA, and only 5 states had historical FFS program quality data available (Colorado [2013], Illinois [2013], Kansas [2003-2008], North Carolina [2010], and Vermont [2012]). It is worth noting that the 5 states that had historical data generally reported more measures (ie, at least 3 measures: Colorado [9 measures], Illinois [3 measures], Kansas [4 measures], North Carolina [3 measures], and Vermont [10 measures]). As shown in Figure 1, the overall quality of diabetes care was low, although generalizations should be made with caution because of the small number of states with publicly reported data and the variance in the age of the reported data. In comparison, however, national benchmark data from the National Committee for Quality Assurance, the organization responsible for the development and maintenance of the HEDIS measures, shows that the proportion of members receiving HbA1c testing was 94% in 2014; the percentage of members with poor control (HbA1c >9%) was 19%.

Contrary to FFS programs, in the assessment of the 10 Medicaid MCOs, they all used the HEDIS core set of measures and had more recent data reporting time frames (all but 1 MCO reported data from 2013 or 2014). The most commonly reported measures were the process (screening) measures: HbA1c testing, eye examination, and LDL-C screening.

The degree and timing of reporting diabetes quality measures differed significantly among states, and historical data were found to be scarce. There was sometimes a significant lag in the time from measurement to reporting of data (eg, 3 years from time of data measurement to report date in Wyoming, Louisiana, and Arizona). Overall, states did not consistently report quality measures on an annual or other regular interval. Moreover, a significant difference exists between Medicaid FFS program populations and MCO populations in terms of their available data. Despite many states’ transitioning their Medicaid population from FFS plans to MCO plans that monitor performance via well-established HEDIS quality measures, the current state of reporting for Medicaid FFS programs remains inadequate. The issue of poor or low levels of public reporting of quality measures is an important one. One of the strategic goals and objectives of the US Department of Health and Human Services (HHS) plan for 2014 through 2018 is to strengthen and improve healthcare quality and patient safety.

 However, improvements can be recognized only if the measures are standardized across the various stakeholders and organizations and the performance data on quality measures are shared regularly. It is not known whether the states identified in this report were influenced by the ACA to report quality measures; although the ACA states that the HHS must publish and periodically update the Medicaid Adult Core Set, participation and reporting by Medicaid programs is voluntary. Although only 4 states had public reports that predated the availability of the Medicaid Adult Core Set (2012), it is not known whether the remaining 19 states that reported ≥1 measure began reporting because of this or whether the timing was coincidental.

There are ongoing initiatives that seek to enhance reporting within various Medicaid populations and more, such as the CMS Innovation Center’s State Innovation Models (SIMs) and other state-level multipayer initiatives, which, perhaps, indicates that changes are on the horizon. In this assessment, 40 states were identified as either participating in SIMs or otherwise establishing larger statewide quality initiatives, with 22 of them tracking at least 1 diabetes-related measure. Because funding for these plans began in April 2013, these initiatives are still in their infancy, with only baseline outcomes data available for review at the time of publication. However, it is anticipated that the level of visibility for progress in diabetes care will continue to increase as states continue to leverage the availability of these funding awards to test innovative health system management approaches.

With the continued expansion of Medicaid and the increasing number of eligible beneficiaries, continuous quality improvement and the impact on outcomes for patients will remain a top priority in the US healthcare system. The recognition of improvement, however, will begin only with the establishment of quality-driven benchmarks and consistent reporting within Medicaid programs.

: Robert Bailey and Janice Lopez are employees of Janssen Scientific Affairs. Marie Smith is a paid consultant to Janssen Scientific Affairs. Herman Chen is an employee of Xcenda, which received funding from Janssen Scientific Affairs to conduct this research.

: Jessica Black, Xcenda, for research and Evelyn Sarnes, Xcenda, for manuscript development assistance.

: Concept and design (JMSL, RB, HC); acquisition of data (HC); analysis and interpretation of data (HC, JMSL, RB, MS); drafting of the manuscript (HC, MS, RB, JMSL); critical revision of the manuscript for important intellectual content (HC, JMSL, RB, MS); statistical analysis (HC); provision of patients or study materials (HC); obtaining funding (JMSL, RB); administrative, technical, or logistic support (HC); and supervision (JMSL, MS, RB).

1. Centers for Medicare & Medicaid Services. Medicaid & CHIP: August 2015 monthly applications, eligibility determinations and enrollment report. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/monthly-reports/index.html. Published October 26, 2015. Accessed November 4, 2015.

2. National Quality Forum; Measure Applications Partnership. Strengthening the core set of healthcare quality measures for adults enrolled in Medicaid, 2014. Final report. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=78283. Published August 29, 2014. Accessed November 5, 2015. 

3. The Henry J. Kaiser Family Foundation. Medicaid and managed care: key data, trends, and issues. https://kaiserfamilyfoundation.files.wordpress.com/2012/

02/8046-02.pdf. Published February 2012. Accessed November 4, 2015.

4. US Department of Health & Human Services. 2014 annual report on the quality of health care for adults enrolled in Medicaid. https://www.medicaid.gov/medicaid/quality-of-care/downloads/2014-adult-sec-rept.pdf. Published November 2014. Accessed November 5, 2015.

5. National Committee for Quality Assurance. 2014 accreditation benchmarks and thresholds — mid-year update. http://ww2.ncqa.org/Portals/0/PolicyUpdates/Trending%20and%20Benchmarks/2014_BENCHMARKSANDTHRESHOLDS.pdf. Accessed November 3, 2015.

6. US Department of Health & Human Services. Strategic goal 1: strengthen health care. http://www.hhs.gov/about/strategic-plan/strategic-goal-1/index.html. Updated February 9, 2016. Accessed November 3, 2015.

Articles

In a review of publicly reported diabetes quality measures for Medicaid fee-for-service, overall reporting was low and reports of outcomes measures were rarely available.