Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs
Title IV of the Children's Health Insurance Program Reauthorization Act (CHIPRA; Public Law 111-3) required the Secretary of the U.S. Department of Health and Human Services (HHS) to identify and post for public comment by January 1, 2010, an initial, recommended core set of children's health care quality measures for voluntary use by Medicaid and Children's Health Insurance Programs (CHIP), health insurance issuers and managed care entities that enter into contracts with such programs, and providers of items and services under such programs.
This background paper describes the publicly transparent, multi-stakeholder, evidence-informed process the Secretary used to identify that initial, recommended core set and the results of that process. Table 1 summarizes the measure set; additional details on the measures can be found in the results section and in the appendix. For a key to the acronyms and abbreviations used in this report, select Appendix A-1.
The initial core measure set includes one or more measures for almost all of the health care topics and criteria specified in the legislation. Also in line with the CHIPRA requirements, quality measures are recommended for services to prevent disease and promote health and to treat and manage a spectrum of acute and chronic conditions experienced by children, including physical, mental, and dental disorders. The measure set includes measures designed to assess family experiences of care (FEC) and availability of services. Measures address services provided across the age continuum and in both ambulatory and inpatient settings. All but five of the measures are supported by evidence for a relatively high level of validity. The validity ratings for others are supported by substantial professional consensus.
There were, however, a number of legislative topics for which currently available, valid, and feasible measures could not be identified, and some legislative criteria that could not be met. These include measures of the "most integrated health care delivery settings" (e.g., the medical home), more valid measures of availability of services, and importantly, a core measure of duration of enrollment and coverage for use in quality reporting. Measures are also needed to assess the outcomes of health care, the quality of children's care for mental health and substance abuse services, other specialty services, and care in inpatient and emergency settings, as well as settings not part of the mainstream medical delivery system.
In addition, neither the recommended measure set as currently specified, nor the body of measures in use by Medicaid, CHIP and others, currently meet the CHIPRA goals of measuring and improving quality across all enrollees in Medicaid and CHIP programs and identifying disparities by race and special health care needs status. Thus, additional work is needed to develop measures and specifications to meet these challenges and to provide technical assistance to the Medicaid and CHIP programs and the plans and providers on which they rely to deliver high quality care. The CHIPRA legislation was visionary in seeing to the future work that would be needed to fully implement and use a core measure set across Medicaid and CHIP programs, as well as other public and private purchasers and programs.
Initiatives are under way at the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) to meet these challenges. For example, in response to CHIPRA, the Secretary has issued a solicitation for grant applications from Medicaid programs, the results of which will contribute enormously to measure improvement, implementation of quality improvement strategies, and the use of health information technology (health IT) to facilitate the use of health care quality measures for children.1 CHIPRA also provided for a program of grants and contracts to advance and improve pediatric quality measures and called for State reporting to the public and to Congress (via the Secretary). Other activities include efforts to consider the initial core set in pay for performance, health IT, 2 and other CMS efforts to facilitate implementation of the measures across the Medicaid and CHIP populations. These include further development of the Federal-State National Quality Framework.
The public comments called for in the Federal Register Notice to which this background paper is linked will be fully utilized in all efforts to facilitate use of the measures. As the capstone for measure development and enhancement, CHIPRA set a target date of January 1, 2013, for identification of an improved, recommended core measure set. In summary, stimulated by CHIPRA and building on our and the States' longstanding interest in health care quality improvement, HHS and the States are rejoining their efforts to use the measures to identify areas in need of improvement and monitor progress toward the goal of a high quality health care system for all children.
Select for Table 1