Improving Measurement of Key Health Insurance Programs: CMS Seeks to Require State Reporting of Core Measure Sets

Post Written by Dr. Ken Robin, Chief Data Analyst

A proposed rule change from CMS would require state reporting on core measure sets for Medicaid and CHIP, programs that cover 88 million Americans, paving the road to the most comprehensive quality dataset ever collected for these key programs.

As a logical next step in a decades-long progression of quality measurement for Medicaid and the Children’s Health Insurance Program (CHIP), CMS is proposing mandatory state reporting and compliance requirements for three measure sets:

·  Core Set of Children's Health Care Quality Measures for Medicaid and CHIP

·  Core Set of Adult Health Care Quality Measures for Medicaid (BH measures only)

·  Core Sets of Health Home Quality Measures for Medicaid

Considering that these two programs now cover 88 million Americans, including more than 40 million children and many highly vulnerable populations, CMS is attempting to lay out a quality measurement plan that will better define current conditions and illuminate opportunities to strategically and efficiently improve outcomes, particularly for underserved populations.

Historical Context: Quality Measurement Gets Off the Ground 

Though Medicaid has been around since 1965, and CHIP since 1997, no federal requirements around quality measurement existed for either program until the CHIP Reauthorization Act of 2009 (CHIPRA). Some states initiated quality tracking on their own, but with no federal guidance or standardization of protocols, data generated from these efforts were predictably messy. States collected data on different measures, according to their own priorities, and varied widely in data infrastructure and capability. There was no way to reliably assess quality or compare across states, or even to know which populations were being tracked for which measures. In 2009, CMS set about trying to create order from chaos.

Among the expanded requirements included in CHIPRA was the establishment of a Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP, or more briefly the Child Core Set. Following consultation with a “variety of interested parties,” CMS released an initial Child Core Set of 24 measures in 2009, and states began voluntarily reporting in FFY 2010. That same year, quality measurement won another victory with the Affordable Care Act, which essentially extended the logic of CHIPRA to now include Medicaid eligible adults. Accordingly, in 2012 CMS issued an initial set of 26 measures comprising the Adult Core Set, and voluntary reporting at the state level commenced in FFY 2013.

The third set of quality measures included in the new CMS requirement applies to health home services provided as part of an optional Medicaid benefit that states were allowed to begin covering in 2011 under section 1945 of the Social Security Act. As of June 2022, 19 states and DC have launched 34 different approved programs. Health homes are recognized providers or groups of providers that are expected coordinate and integrate all primary, acute, and behavioral health services, as well as long-term care and supports for patients and families. The benefit is available to individuals with multiple chronic conditions such as asthma, SUD, heart disease, diabetes, obesity, or mental health conditions. A recent expansion of the concept (section 1945A) will allow health home benefits for Medicaid-eligible children with medically complex conditions, with state implementation allowed as of October 2022.

The move to track quality was consistently applied to health home services, with a set of reporting measures (the Health Home Core Set) published by CMS in 2013. With a nod to reporting burden, all but one measure aligned with existing measures in the Adult Core Set, and reporting on the Health Home Core Set would be voluntary. A unique feature of health home reporting is that data must be aggregated at both the provider and health home level, as opposed to state-level only, as is the case for the Child and Adult Core Sets.

Quality Measurement Gains Altitude

All three Core Sets are reviewed annually and have undergone significant revision over the years. The goal of a national, standardized, evidence-based system of quality measurement and improvement has proven to be a long-term endeavor. Honing of the Core Sets is accomplished through Annual Review Workgroups, which ensure measures remain current, meaningful, and feasible. These workgroups benefit from the perspectives of multiple stakeholder groups, including states, primary and specialty care providers, hospitals, dental professionals, and national organizations representing relevant populations. At a minimum, measures are expected to be:

1. Evidence-based and risk-adjusted (quality)

2. Designed to identify and eliminate racial and ethnic disparities in health and the provision of health care (equity)

3. Designed to ensure that data required for such measures is collected and reported in a standard format that permits comparison of quality data at a state, plan, and provider level (reliable)

4. Periodically updated (current), and

5. Responsive to health needs, services, and domains of health care quality described in the relevant legislation (valid)

These five expectations directly address key components that will ultimately determine the usefulness of core data sets. If CMS is to use this information to drive quality improvement by comparing outcomes across states and across demographic groups, then selected measures must accurately reflect current beneficiary needs.

The current Core Sets borrow heavily from established measure sets. For example, the Child Core Set for 2022 consists of 25 measures, 15 of which are pulled from NCQA’s HEDIS measures. Questions are grouped into domains such as Primary Care Access and Preventive Care, Maternal and Perinatal Health, Behavioral Health Care, and one question on Experience of Care taken from the CAHPS consumer survey. The Health Home Core Set is shorter and focused heavily on behavioral health, with a total of 13 outcome and utilization measures. 

Throughout the voluntary reporting years, the number of measures reported by states and health home programs has increased each year. CMS publicly reports on an individual measure if at least 25 states or 15 health home programs submitted quality data. In the first year of reporting for the Adult Core Set (FFY 2014), 10 measures were reported. By FFY 2020, public reporting was possible for 28 of 33 Adult Core Set measures. However, reporting gaps and shortcomings remain, including that many states do not report measures for all beneficiaries, severely limiting the ability to compare across states or understand demographic disparities.

States are supported in the annual reporting process through a variety of resources offered by CMS’s Technical Assistance and Analytic Support Program. Supports include webinars, manuals, data quality checklists and timelines, as well as learning collaboratives in specific quality areas. These collaboratives are intended to help translate data into action by building knowledge of evidence-based interventions and how to conduct quality improvement projects.

Future Challenge  – Uniform Quality Measurement Promotes Equity and Excellence for All?

Two bills signed into law in 2018 mandate reporting of the Child Core Set measures, and the behavioral health measures of the Adult Core Set. The new laws are designed to address limitations of voluntary reporting and fulfill the promise of the Core Sets to truly drive quality improvement. Mandated reporting, following a standardized format, is slated to begin with the annual report for FFY 2024. The new proposed rule would extend mandated reporting to identified measures on the Health Home Core Set, as well as a new section 1945A Health Home Core set, which will be developed and periodically updated following the launch of 1945A programs. The same Annual Review Workgroup will oversee both the 1945 and 1945A Core Sets, with states required to report based on which section its program(s) were approved under. The argument for establishing reporting requirements concurrently for all four measure sets is to align quality reporting programs and ease the burden on states through common processes and standards.

To help get the proposed requirements off to a successful start, CMS is offering an array of guidance and supports, as well as a phase-in approach to new rules. Part one of the guidance would specify which measures on the Child, Adult, and both Health Home Core Sets are mandatory, and if additional time to report would be provided for any measures. Part two would detail “form and manner” requirements for reporting, including how to collect and calculate Core Sets data. Additionally, CMS reporting guidance would specify which populations must be reported for each measure, providing detailed attribution rules to address complexities such as transitions between Medicaid and CHIP or between different eligibility groups, delivery systems, or managed care organizations (MCOs).

Though details are not yet available, it seems likely that reporting will not be required for all Core Sets measures immediately in FFY 2024. Measures that may merit extra time include new additions to Core Sets following annual review, and complex measures that require more intensive data collection to report. Some Core Sets measures are “administrative,” which are relatively straightforward to report and typically can be calculated from claims data. Others are referred to as “hybrid” measures, which often require additional clinical information from medical records, thus are far more time-consuming to report. States will receive guidance on how to approach these new or more complex measures but will almost certainly not be mandated to report data for all of them in year one of the new requirements.

Year-to-year, states will receive reporting guidance on populations for which they are expected to report data. Currently, data availability limits or precludes states’ ability to report on several populations, including dually eligible beneficiaries, beneficiaries served by Indian Health Service or Tribal Organizations, beneficiaries served by FQHCs, and beneficiaries receiving services on a fee-for-service basis in a state with large MCO enrollment. CMS acknowledges that proposed new reporting requirements can only be successful after changes in data infrastructure and availability provide avenues around some current barriers. For example, many states need technical assistance requesting and analyzing the Medicare data that are necessary to report Adult Core Set measures for dually eligible beneficiaries. Similarly, state Medicaid agencies may not receive claims data from IHS or FQHCs. FQHCs and look-alike agencies do report to a Uniform Data System (UDS), but information in the UDS is not sufficient to calculate all Core Set measures. States that have largely moved to managed care rely on MCOs for data and lack infrastructure to report for their small FFS populations. To help meet these and other challenges, the new reporting rules come with an enhanced Federal Medicaid match for systems development and maintenance.

Reporting of Core Sets data would also need to be consistent with requirements outlined in the Biden administration’s Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, which is essentially a call for fairness to be embedded in the day-to-day thinking and practices of government. As such, where possible Core Sets data would be stratified by factors such as race, ethnicity, sex, age, and disability status. States will not be given flexibility to decide which measures can be stratified or which demographic factors to address. The rationale behind this decision is that consistency is necessary to optimally identify health disparities and understand health outcomes in underserved populations. Interventions to address these disparities are also best evaluated if state reporting is standardized.

Requiring data stratification is complicated by the fact that demographic data available to states and CMS have historically been woefully incomplete. Beneficiaries are not required to report race, ethnicity, or disability status, and many do not. CMS has developed imputation techniques such as geocoding, but these approaches are quite limited and data collection approaches that yield higher response rates for demographic information would greatly improve the ability to assess health disparities. Further complicating matters are data privacy and cell suppression policies that may apply to smaller populations or smaller programs when disaggregated by demographic factors.

To assist states as they move towards stratified reporting, CMS is proposing a phase-in approach. Once the Secretary identifies which measures need to be stratified, and by which reporting groups, states will be expected to submit stratified data for 25% of those measures by the second year after finalization of reporting rules. Years three and four will require stratification of 50% of identified measures, and beginning in Year five, all measures identified for stratified reporting must be submitted as such.

CMS is considering whether to also require reporting of the Child Core Set and behavioral health measures of the Adult Core set by delivery system. States would need to identify whether a beneficiary received a service on a fee-for-service basis or through a Managed Care Organization. CMS is seeking public comment on the feasibility of this requirement.

The Future of Cohesive National Measurement & Improvement

If successful, standardized reporting of Core Sets measures will significantly clarify true impacts of care provided to beneficiaries and allow legitimate scaling of best practices. States could learn from each other and engage in strategic, targeted improvement efforts. A clearer national understanding of health care quality and equity would be fostered, and the pace of change would likely be hastened. With so much at stake, financial penalties are available to provide leverage for CMS to enforce quality measure reporting. Regulations would allow CMS to withhold federal Medicaid payments, in whole or in part, from a state that is non-compliant with reporting requirements.

The proposed new rule is complex, potentially deeply influential, and as yet far from fully defined. CMS is accepting public comment on all the considerations and policies outlined above through October 21. Comments with reference to file code CMS-2440-P may be submitted electronically at http://www.regulations.gov.

Understanding quality measurement sets and their respective incentives is key to understanding how your institution fits into the broader health ecosystem and how best to position your value proposition to increase results or enter a new market. If you’re a health care company seeking to enter the Medicaid market, reach out to our team to learn more about how we can support your Medicaid goals.

About the Author: Dr. Ken Robin is the Chief Data Analyst at HSG.