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Low Reporting of Medicaid Diabetes Quality Measures: Room for Improvement?

In a review of publicly reported diabetes quality measures for Medicaid fee-for-service, overall reporting was low and reports of outcomes measures were rarely available.
Published Online: Nov 16,2017
Janice M. S. Lopez, PharmD, MPH; Robert Bailey, MD; Marie Smith, PharmD; and Herman Chen

Background: The provision of high-quality healthcare is a priority for US health plans and the CMS. Health plans can implement quality initiatives to ensure appropriate healthcare for their beneficiaries and use quality measures in their various initiatives to assess quality of care and outcomes.
Methods: We reviewed publicly reported diabetes quality measures for Medicaid fee-for-service (FFS) programs in all 50 states and the District of Columbia. Our objective was to provide insights into the extent of diabetes quality measure reporting (ie, which diabetes quality measures are being reported and what percentage of states are using the diabetes Healthcare Effectiveness Data and Information Set [HEDIS] measures) and into the quality of care being provided (ie, achievement of established goals in diabetes care and state-level performance on diabetes quality measures).
Results: Overall, the number of Medicaid FFS programs reporting these data was low: 23 states reported data on at least 1 HEDIS measure. The most common measures reported were process measures (eg, retinal eye exams and HbA1c testing); outcomes measures such as the proportion of patients achieving goal were much less frequently available. Few states had historical data available, which limits the opportunity for retrospective analyses or quality benchmarking.
Conclusions: This research is important, as an understanding of the current landscape of quality measures for the Medicaid diabetes population is critical to designing and implementing initiatives aimed at improving the quality of care for individuals living with diabetes.

                                                                                          Am J Pharm Benefits. 2017;9(6):185-189

The provision of high-quality healthcare is a priority for the United States, in large part as a result of the Affordable Care Act (ACA) and its focus on 3 goals to improve the experience of care, improve the health of populations, and reduce the per capita costs of healthcare. These triple aims also guide the National Quality Strategy that was established as part of the ACA, which describes the national priorities and strategic plan for quality improvement in healthcare. 

This reformative health policy environment has spurred many organizations to call for methods to measure, track, and improve the provision of healthcare and engage in the nationwide conversation regarding the definition of “value.”

Medicaid is responsible for providing healthcare coverage to more than 72 million beneficiaries.1 The population served by Medicaid will continue to expand under the ACA. The CMS has been a major forerunner in implementing quality healthcare measures and has implemented ongoing initiatives to ensure quality healthcare for both Medicare and Medicaid beneficiaries through accountability and public disclosure.

The ACA required the implementation of a core set of healthcare quality measures for adults participating in Medicaid. The initial set of measures was released in 2013.2 Reporting by states is voluntary; however, many states now require Medicaid managed care plans to report quality measures using the Healthcare Effectiveness Data and Information Set (HEDIS) tool. Although Medicaid is shifting away from a traditional fee-for-service (FFS) model, a substantial number of complex beneficiaries remain within this structure (eg, those with multiple chronic conditions and high resource utilization) and account for a disproportionate amount of total Medicaid expenditures.3 As such, we sought to explore the availability and breadth of data from quality measurement programs that traditional FFS Medicaid plans and Medicaid managed care organizations (MCOs) have instituted for patients with diabetes.


Diabetes-related quality data were obtained as of July 2015 through a Web-based search of publicly reported data, such as state Medicaid and related websites (list of websites provided in Table 1). This research included a review of all 50 states’ Medicaid FFS programs, the District of Columbia, and the largest Medicaid MCO in the 10 states with the highest Medicaid enrollment through May 2015: California, New York, Texas, Florida, Illinois, Ohio, Pennsylvania, Michigan, Georgia, and New Jersey. For purposes of this research, a Medicaid MCO was defined as a contracted entity that administers Medicaid benefits on behalf of a state. Because of the inconsistencies observed in the degree and time frames with which Medicaid FFS plans reported their diabetes-related quality data on public websites, the investigators reached out personally to a 10% sample of states to validate the completeness of data that were captured after the initial Web-based research was completed. Medical and quality program directors at 5 state Medicaid FFS programs (California, New York, Florida, Ohio, and Michigan) were contacted via phone and/or e-mail by the research team. For each state, a director of policy and quality, or similar role, was sought to provide confirmation on the data. These 5 states were chosen for the sample because they include the greatest number of covered lives under their FFS models.

Data Collection and Analysis
The extent of diabetes-related quality measures found included mostly HEDIS Comprehensive Diabetes Care indicators (both current and previous measures), such as:
  • Hemoglobin A1C (HbA1c) testinga
  • HbA1c poor control (>9.0%)
  • HbA1c poor control (<8.0%)
  • HbA1c control (<7.0%)
  • Eye exam (retinal)a
  • Medical attention for nephropathya
  • Blood pressure (BP) control (<140/90 mmHg)
  • BP control (<140/80 mmHg)
  • Low-density lipoprotein cholesterol (LDL-C) screeninga
  • LDL-C (<100 mg/dL)
aDenotes a process measure.

Other non-HEDIS diabetes-related quality measures were also identified and documented when found. When provided, the percentage of Medicaid patients meeting each quality indicator in each program was captured. Quality data were analyzed by examining the states’ individually published information for trends in Medicaid program reporting and performance while also noting those Medicaid plans that did not report any data.

All 50 states and Washington, DC, reported using HEDIS as their quality reporting system for either Medicaid FFS or MCO patients. For FFS programs, publicly reported data on diabetes quality measures were poor, with only 23 states (45%) having published data on at least 1 HEDIS measure for their FFS Medicaid lives or total Medicaid lives (Figure 1). We also found that the data-reporting period (ie, the date of the data available on the websites) varied widely, from as early as 2002 through March 2015. Only 6 states reported data from the previous year (2014; Colorado, Illinois, Tennessee, Florida, Vermont, and Connecticut). Only Colorado, Florida, and Vermont reported 7 or more HEDIS diabetes quality measures. Other non-HEDIS diabetes measures identified included hospital admissions rate for short-term complications associated with diabetes, hospital admissions rate for long-term complications associated with diabetes, proportion of patients with microalbuminuria, proportion of patients receiving screening for microalbuminuria, proportion of patients classified as obese or overweight, receipt of influenza vaccine in adults aged 50 to 64 years, health literacy, tobacco use, and composite measure of HbA1c, low-density lipoprotein cholesterol (LDL-C), blood pressure, and tobacco use.