5. Recommendations for Future Core Sets and Measurement
Refinement and Development
discussions within the workgroups and among the Subcommittee as a whole, members
offered ideas for how to identify priorities for future iterations of the Initial
Core Set; how to improve current measures; and suggested strategies for
collecting, aggregating, and reporting data that may extend the Initial Core
Set's usefulness and potentially minimize burden for States.
The Subcommittee made
recommendations regarding the process of measure identification, development,
and enhancement. First, they encouraged the involvement of stakeholders throughout
the measure development and enhancement process so that new measures developed will
provide information relevant and meaningful to them. Second, they recommended a
focus on measures that will lead to improvement in performance and health
outcomes. Finally, they recommended looking more broadly to measures that can
be used in other settings (e.g., long-term care services and supports as well
as home and community-based services).
The Subcommittee highlighted topic
areas and particular Medicaid populations for which measures were lacking. The Subcommittee
also identified topic or clinical areas where measures currently exist, but potentially
could be further honed and included in future Core Sets.
general, the Subcommittee noted the importance of a continued focus on specific
adult Medicaid beneficiaries: women, individuals with mental health/substance
use problems, individuals with complex health care needs, frail elderly, and
individuals with disabilities. While measures exist for many conditions common across
Medicaid adults (e.g., diabetes), they are not typically specified for individuals
with severe mental illness and, in fact, often exclude these populations from
the denominator. For conditions that are less common in the general population,
measures often do not exist altogether (e.g., dementia, viral hepatitis,
Alzheimer's disease). The Subcommittee also expressed a need for more measures
that assess the quality and content of care received. Many existing measures
focus on the number of visits a patient had (e.g., women who had the requisite
number of prenatal and postpartum care visits) but not the quality of care
received or health outcomes as a result of the care provided. The Subcommittee acknowledged
that information on content and quality of care is difficult to collect using
current data sources.
Subcommittee noted the following important areas for priority populations:
Health. Many measures in the women's
health domain focus on access to care (particularly for pregnancy). There are
existing measures in use that assess secondary prevention (i.e., screenings) in
women, and many of these measures were recommended for the Initial Core Set. However,
there is a need for measures that promote the full range of women's health
needs, such as:
Measures addressing pre-conception
care, including gynecologic care and screenings for sexually transmitted
infections (e.g., human papillomavirus, hepatitis).
Conditions and procedures that impact
women (e.g., hypertension, urinary incontinence, hysterectomies).
Pregnancy and postpartum care
measures that go beyond measuring access to care (e.g., ensuring vaccinations
and proper screenings during pregnancy, healthy birth outcomes such as progesterone
treatment to reduce pre-term births).
with complex health care needs, frail elderly, and those with disabilities. Due to the complex management and treatment needs for
people with multiple chronic and complex health care needs, in these areas,
feasible measures are lacking. Refining existing measures and development of
additional measures could address topics such as:
Age bands and exclusions for
measures that exclude dually-eligible beneficiaries or those beneficiaries with
long-term care needs and social supports (e.g., consider modifying the measures
for the AHRQ Prevention Quality Indicators for dehydration, bacterial
pneumonia, and urinary tract infection to include institutionalized
- Conditions and topic areas with a
particular impact on these populations (e.g., falls/fractures, pneumonia, quality
of life, safety, HIV/AIDS screenings).
- Social supports (access to,
quality of, etc.).
Health/Substance Use. As raised by
the Mental Health and Substance Use workgroup and other Subcommittee members,
measures in this area may be challenged by small denominator issues. However,
measures are needed in areas that address:
- Brief interventions.
- Medication treatment for opiate
use and alcohol.
- Antipsychotic use.
- Ambulatory sensitive conditions or
preventable hospitalizations related to mental health conditions.
addition, the Subcommittee recommended that future measurement activities
consider focusing across populations:
outcomes and risk assessments. This
area is one in which measures are minimal due to the difficulty of collecting
such information using current methods. In particular, effective measures are
needed that can address concepts such as quality of life and choice and autonomy
in treatment/setting (e.g., advance care planning). Additional topics that
warrant attention in this area include:
- Pain assessment and management.
- Functional status.
- Measures that capture the perspective
management and safety. Due to the
limitations of existing data sources, many existing medication management
measures only assess "prescription dispensed" and may not adequately assess "adherence."
Future measurement development topics that may be able to leverage EHRs or
other clinically enriched data include:
- Safety of psychotropic medication.
- Management of pain medication.
- Integration of physical and
coordination. Measures that assess
care coordination can be difficult to develop and collect. Measures that assess
the following areas were particularly noteworthy for the Subcommittee:
- Medication reconciliation.
- Care transitions.
- Shared accountability (across
providers treating the same individual).
access-to-care measures exist for the general population and for many general
services (i.e., screenings), measures that address access to specific services,
such as behavioral health care, are less abundant. Additional areas for which
to measure access include the following:
- Oral health care.
- Emergency department use.
The Subcommittee acknowledged
that many of the gap areas identified lacked usable measures due to the
complexities of gathering data from all the necessary data sources or the
difficulty of incorporating patient-reported outcomes. Care coordination, for
example, requires pulling information from multiple and varied systems that may
not normally communicate with one another. Thus, they recommended consideration
of new data collection/aggregation and analytic methodologies to support new
measures. For example, broader deployment of health information technology in
the health care setting may support increased use of patient-generated data and
clinically enriched datasets that allow for measures assessing health outcomes.
Opportunities to combine Medicare and Medicaid data for people with dual
eligibility and integration of data from health information exchanges could be
considered for increasing both the meaningfulness and feasibility of measures.
Cognizant of the data collection burden for States, the
Subcommittee suggested several ways to incorporate alternative reporting
approaches for the Initial Core Set:
of reporting for certain populations, defined by race/ethnicity, Medicaid
eligibility category (disabled, dual Medicare/Medicaid eligibility), or
condition (e.g., serious mental illness). The Subcommittee noted that providing States with a
standardized methodology for stratifying measurement data from the Initial Core
measures would be critical for identifying potential disparities in care or
unmet needs. For example, general population measures such as Medical Assistance
With Smoking and Tobacco Use Cessation or diabetes screening measures could
be reported for people with schizophrenia and bipolar disorder or for people
dually eligible for Medicare/Medicaid.
Rotation. Since efforts to improve
performance on measures are likely to take more than one year, the Subcommittee
recommended rotating measure reporting so that a designated set of measures are
reported every other year or some other specified interval (rather than
annually). In this way, the burden of reporting could be limited without
affecting the usefulness of the information.
Composite measures. The Subcommittee
recommended considering options for creating measure composites that would provide
high-level information about care.
of different supplemental sets into the Consumer Assessment of Healthcare
Provider and Services (CAHPS®) surveys. The Subcommittee recommended the use of the CAHPS Health
Plan survey and the HEDIS Supplemental CAHPS set but also noted that other
supplemental sets exist for CAHPS addressing important topics for the Medicaid
population (e.g., Cultural Competence).
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