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

II. Context

To inform its deliberations, AHRQ and CMS officials provided the Subcommittee with background information on two key topics: The populations served by Medicaid and the current state of quality reporting in Medicaid. This information helped to inform discussions about the health care needs of the Medicaid population and the challenges in developing a core set of measures to assess how well those needs are met.

Medicaid-Eligible Adults

Medicaid programs serve a diverse group of adults, and the needs of these populations were important considerations in the selection of the initial core set of quality measures. In fiscal year 2009, about 27 million adults were enrolled in Medicaid over the course of a year, accounting for about half of Medicaid beneficiaries nationwide (USDHHS, 2009a). As health care reform is implemented, the number of adults enrolled in Medicaid is expected to increase.

As a Federal-State program that serves low-income population, Medicaid bases coverage on whether an individual qualifies under financial and categorical eligibility rules. Non-elderly adults comprise about half of the adults enrolled in Medicaid. This includes a large share of women who are eligible for coverage due to pregnancy or being the parent of a dependent child. Thus, maternal and reproductive health is a key concern when identifying measures for adults enrolled in Medicaid. Medicaid covers 4 of 10 births nationwide (National Institute for Reproductive Health, undated).

Fifteen percent of Medicaid enrollees are individuals with physical, mental, or intellectual disabilities under age 65, and 9 percent are elderly, age 65 and older (USDHHS, 2009b). Some adults in Medicaid have dual eligibility for Medicare and Medicaid, and of these, about one-third are under age 65 (Medicare Payment Advisory Commission, 2010). While people with disabilities and elderly are only 25 percent of the Medicaid population, they account for 70 percent of Medicaid expenditures (Eiken et al., 2007).

Medicaid is the largest payer of long-term care in the United States and accounts for about half of all long-term care (including both institutional and community services) in the United States (Georgetown University, 2007). The long-term care population covered by Medicaid includes 2.2 million individuals with varying health care needs.

Quality Reporting in Medicaid

Given the legislative requirement that measures designated for the core set be currently in use, the Subcommittee also considered the current state of quality reporting in Medicaid. There is no one standardized set of measures used across all States for quality reporting for Medicaid; however, measures developed for managed health care plan reporting are available and frequently used. A recent report showed that most States use Healthcare Effectiveness Data and Information Set (HEDIS®) measures or measures similar to HEDIS; 36 States reported using these measures with managed care organizations and 22 States used them with primary care case management (PCCM) or in fee-for-service (FFS) (Smith et al., 2009).

States that use HEDIS measures frequently modify HEDIS measures by altering enrollment periods, measurement year, and numerator requirements, and by using different validation procedures or data collection processes (NCQA, 2010a). While less is known about how States use quality reporting in FFS and PCCM programs, a report by the Center for Health Care Strategies (CHCS) highlighted practices from eight States that do. The report recommended that States begin measurement efforts and involve providers and other relevant stakeholders while paying attention to the challenges and resource needs (Lind et al., 2010). The States interviewed as part of the CHCS report noted that resources would be needed for measurement and validating results. States were also encouraged to begin by using measures available from administrative data sources.

Page last reviewed October 2014
Page originally created September 2012
Internet Citation: II. Context. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.