National Advisory Council Subcommittee: Identifying Quality Measures for Medicaid-eligible Adults

Appendix 10. Public Comments

March of Dimes
Adult Health Quality Measures for Medicaid Eligible Adults
October 18-19, 2010

Good afternoon. My name is Amanda Mazek, and I thank you for this opportunity to offer comments on behalf of the March of Dines Foundation regarding the development of a core set of adult health quality measures for use in Medicaid. The March of Dimes is a unique collaboration of scientists, clinicians, parents, members of the business community, and other volunteers affiliated with 51 chapters representing every State, the District of Columbia, and Puerto Rico. Founded originally to support research and services related to poliomyelitis, today the Foundation focuses on research, education, community programs, and advocacy to improve the health of women of childbearing age, infants, and children by preventing preterm birth, birth defects, and infant mortality.

As you may know, the March of Dimes has been deeply engaged in promoting greater quality measurement, reporting, and improvement in the Medicaid and CHIP programs. The March of Dimes was one of the first organizations to urge Congress to call for the development of a core set of pediatric quality measures for use in Medicaid and CHIP as part of the CHIP Reauthorization Act. And our success on CHIPRA set the stage for promoting additional investments in health information technology in ARRA. The CHIPRA quality language also served as the basis for the provision in the Patient Protection and Affordable Care Act that calls for the development of a core set of adult health quality measures for use in Medicaid.

Given that Medicaid currently finances and estimated 42 percent of births nationwide, and as many as two-thirds of births in some States, the March of Dimes feels it is imperative that the core set of adult health quality measures include maternity care. We believe it is essential that quality measures and data reported by States present a comprehensive picture of how well Medicaid is serving pregnant women, what is working well, and also where improvements are needed. Given that pregnancy is the largest health expense a young healthy woman and her family are likely to experience, a focus on maternity care can also help to improve the quality of services provided while reducing unnecessary Medicaid expenditures and thereby bending the cost curve.

The March of Dimes recognizes the difficult task facing States in paying for an administering their Medicaid programs. We therefore are recommending inclusion in the core set only those key measures that are already well vetted and widely in use. One such measure, which has already been approved by the National Quality Forum (NQF) and is included in the Joint Commission's core set of perinatal measures, pertains to elective deliveries between 37 and 39 weeks of gestation. A January 2009 study published in the New England Journal of Medicine found that elective cesarean sections and inductions before 39 weeks pose significant risks to infants' health, including respiratory problems, feeding difficulties, infections, and higher rate of neonatal intensive care unit admissions.1 These increased health problems lead to higher rates of utilization of health care services and ultimately higher health care costs.

Adopting this measure will not only lead to improved care for both pregnant women and their infants, but also has the potential to reduce unnecessary Medicaid costs as the final weeks of pregnancy are a very important period of fetal lung development and brain growth, and the health consequences for children born 37-39 weeks gestation with no medial indication can be significant and require costly care. Considering these complications, the American College of Obstetricians and Gynecologist (ACOG) recommends that non-medically indicated cesarean delivery should not be performed before a gestational age of 39 weeks unless there is verification of lung maturity.2

In addition to this measure, the March of Dimes would also urge you to recommend inclusion of the following maternity measure in the core set:

  1. Pregnant women at risk of preterm delivery at 24-32 weeks gestation receiving antenatal corticosteroids prior to delivery. Antenatal corticosteroids are typically recommended for women at risk or experiencing preterm labor to help the fetus's lungs mature so that he or she can breathe more easily after birth. Corticosteroids reduce breathing problems in newborns and help prevent a serious lung disease called respiratory distress syndrome. Corticosteroids also help prevent bleeding in the newborn's brain and a serious bowl disease called necrotizing enterocolitis. This measure is NQF-approved and included in the Joint Commission's core set.
  2. Prophylactic antibiotic in cesarean section. All women undergoing cesarean delivery without evidence of prior infection who received prophylactic antibiotics within one hour prior to surgical incision or at the time of delivery. This practice can help reduce postpartum infections and this measure has been approved by NQF.
  3. Healthcare Effectiveness Data and Information Set (HEDIS) 2010 measure on medical assistance with smoking and tobacco use cessation. This is critically important for pregnant women and particularly timely given that States will be required to cover tobacco cessation counseling for pregnant women in Medicaid beginning in 2011. Inclusion of this measure can help ensure that States are in compliance with the new Federal law and help improve the quality of cessation services. Women who smoke during pregnancy are more likely than nonsmokers to have a low birth weight or preterm baby. According to ACOG, it is estimated that eliminating smoking during pregnancy would reduce infant deaths by 5% and reduced the incidence of singleton low birth weight infants by 10.4%. Given that pregnant women on Medicaid are 2.5 times more likely to smoke than other pregnant women (according to data collected by the Centers for Disease Control and Prevention), it is critically important that this measure be part of the core set.
  4. HEDIS 2010 measure on postpartum care. This measure captures the percentage of women who had a postpartum visit 21-56 days after delivery. Postpartum care has been shown to help women improved appropriate spacing for subsequent pregnancies, reducing the risk of preterm birth with can be devastating for families as well as extremely costly. In fact, a recent Institute of Medicine (IOM) report estimates that the societal economic cost of a preterm birth totaled at least $26.2 billion in 2005, the latest year for weight data is available. The medical component of that cost was $18.8 billion — 85% of which was health services provided to infants. The IOM Committee estimates that more than half of these medical costs are borne by Medicaid and other public programs.

The March of Dimes recognizes and is very grateful that the initial core set of pediatric quality measures for use in Medicaid and CHIP includes four perinatal measures: Frequency of prenatal care; timeliness of prenatal care; rate of cesarean sections for low-risk women; and the percent of live births weighing less than 2,500 grams. We would appreciate the Subcommittee's guidance on whether these measures should also be incorporated into the adult core set. And, of course, we strongly urge you to ensure that your recommendations for the maternity measures in the adult core set take cognizance of and are aligned with the prenatal framework set forth in the pediatric core set.

The March of Dimes recognizes that the current focus for the core set is likely to be measure that are already well vetted and widely in use. However, as this effort continues, the Foundation urges you to recommend explicitly that there be developed additional measure in the arenas of family planning and preconception and interconception care. Appropriately spacing pregnancies — for which access to family planning services in critically important — has been shown to reduce the risk of preterm birth. Numerous studies show that certain health services, if provided to a woman before pregnancy, can improve the health of a future pregnancy. Often, women do not realize that they are pregnant at the outset, and the first prenatal visit with a physician typically does not occur before 6-12 weeks after conception. Beginning care at this point misses opportunities to intervene before crucial early weeks of fetal development. Preconception and interconception care allow providers to identify conditions or behaviors that can impact a future pregnancy and provide appropriate intervention. As part of the Affordable Care Act's Medicaid expansions, the program will begin covering millions more women of childbearing age for who these services are essential. It is important to invest up front in quality measurement to ensure that Medicaid is capturing the information needed to assess the quality of care being provided to this highly vulnerable population.

Once again, thank you for this opportunity to comment, and for all of your work in developing recommendations for consideration by the Secretary. And on behalf of the March of Dimes Foundation, I urge you to include these few, but very important evidence-based maternity care measures on the short list. Doing so will set the stage for significant strides forward in improving the quality of care provided and reducing unnecessary cost of millions of pregnant women and infants who depend upon Medicaid for their health coverage. Thank you.

1 Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes. Tita, A et al. N Engl J Med Jan 8, 2009.
2 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 386 November 2007: cesarean delivery on maternal request Obstet Gynecol 2007;110(5):1209-12.

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BioTechnology Industry Organization
October 18, 2010
Dr. Carolyn Clancy
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, Maryland 20850

Dr. Marsha Lille-Blanton
Chief Quality Officer
Division of Quality, Evaluation and Health Outcomes
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, Maryland 21244-1850

The Biotechnology Industry Organization (BIO) appreciates this opportunity to comment on the development of the core quality measures for the Medicaid Quality Measurement Program created in the Patient Protection and Affordable Care Act. BIO represents more than 1,100 biotechnology companies, academic institutions, State biotechnology, centers, and related organizations across the United States and in more than 30 other nations. BIO members are involved in the research and development of innovated health care, agricultural, industrial, and environmental biotechnology products.

BIO membership includes both current and future vaccine developers and manufacturers who have worked closely with the public health community to support policies that help ensure access to innovative and live-saving vaccines for all individuals. We support the development and use of appropriate, evidence-based quality measures throughout the health care system, and we feel that immunizations have long been considered a proven and cost-effective health care intervention for persons of all ages. Our comments today focus specifically on the need to include immunizations for adults in the core quality measures.

The inclusion of the adult immunization recommended by the Centers for Disease Control and Prevention (CDC) in the core measures will help millions more Americans to reap the benefits of these life-saving vaccines. While immunization coverage for children and adolescents is relatively high in both the public and private sectors, the rates of coverage in the adult populations are meager at best. These low rates lead to unnecessary physician office visits, hospitalizations, and even death. In fact, 99% of the 40,000-50,000 vaccine-preventable deaths in the United States that occur each year are in adults.1 The CDC has estimated that the direct health care burden of adult vaccine-preventable diseases is approximately $10 billion annually.2 Creating quality measures that incorporate adult immunizations will help ensure that health care providers and systems routinely discuss and offer vaccines to their patients.

We would like to highlight four examples of potential quality measures that could be considered by the group:

  • The National Committee for Quality Assurance has numerous adult immunization measures that could be leveraged by this committed. We would call your attention to those measures that strongly reinforce the need to immunize very broad populations against influenza and pneumococcal diseases.3 These broader measures are most closely aligned to the universal recommendation for influenza immunization from the CDC.
  • The Joint Commission/CMS/hospital measure for screening and vaccinating with influenza and pneumococcal of inpatient 50+ presenting with pneumonia facilitates implementation of the quality measure by simplifying the patient identification process.4
  • Another measure that should be considered is education mothers about pertussis and vaccinating them with Tdap vaccine post-partum (upon hospital discharge). This should be considered in light of the recent pertussis outbreaks and is already a current practice among many birthing hospitals.5 Including this measure as part of the discharge order set would be easy to implement and measure and could be structured to mirror the current hospital influenza/pneumonia discharge measures.
  • Lastly the Medicare Personal Prevention Plan that is being implemented as a part of Patient Protection and Affordable Care Act offers an excellent example of one method for routinely introducing patient-specific discussion of appropriate vaccinations.6 Health care providers must create a plan with their Medicare beneficiaries that captures key information and reviews the patient's need for all of the 10 immunizations currently recommended by the ACIP. A Medicaid quality measure that encourages health care providers to evaluate and discuss the recommended adult vaccines appropriate for that individual could help increase awareness by all parties and subsequently vaccination rates.

One of the tenets of health care reform was a harmonization between public and private insurance programs. For commercial plans, according to the Interim Final Rule that took effect on 23 September 2010, all covered individuals are required to have first dollar coverage for all Advisory Committee on Immunization Practices (ACIP) recommended vaccines. Many key decisionmakers in the private sector, therefore, have stated that immunization quality improvement for all adult ACIP recommended vaccines is becoming a new area of focus even in the absence of available quality indicators. Having these quality measures developed and published will even further enhance and incentivize adult immunization improvement. Medicaid should parallel the efforts underway in the private sector and should have to report to Congress on how well they are ensuring access for this significant population. We recommend that any adopted performance measure be as inclusive and comprehensive as possible.


BIO appreciates the opportunity to comment of the development of the core quality measures for the Medicaid Quality Measurement Program created in the Patient Protection and Affordable Care Act. We look forward to continuing to work with AHRQ and CMS to address these critical issues in the future. Please feel free to contact me at ###-###-#### if you have any questions or if we can be of further assistance. Thank you for your attention to this very important matter.

With Sincerest Regards
Phyllis A. Arthur
Senior Director, Vaccines, Immunotherapeutics and Diagnostics Policy
Biotechnology Industry Organization.

1 CDC. National Vital Statistics Reports: Deaths: Final Costs for 2000. Hyattsville, MD; National Center for Health Statistics, 2002.
2 Trust for America's Health, Adult Immunization: Shots to Save Lives. February 2010.
3 — immunization measures as of February 2010.
4 — immunization measures as of February 2010.
5California Department of Public Health, CDPH Broadens Recommendation for Vaccination Against Pertussis: Immunization Key to Controlling Whooping Cough. Available at
6 PL 111-148, Patient Protection and Affordable Care Act 2010: Title IV, Subtitle B, Section 4103.

Page last reviewed October 2014
Page originally created September 2012
Internet Citation: Appendix 10. Public Comments. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.