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Health care overhaul: Ensuring quality care for Medicaid recipients

June 13, 2011 - Mary Ann Heath
In 2007 (the most recent statistics I could find), 58.1 million Americans were enrolled in Medicaid. Changes facilitated by the Patient Protection and Affordable Care Act aim to ensure the millions covered by Medicaid are receiving quality care.

So, are those covered by Medicaid currently not receiving quality care? A quick search on the Internet revealed a 2007 study published by the Journal of the American Medical Association, and the answer was those covered by Medicaid were receiving less quality care than those enrolled in other commercial managed care programs.

A doctor from Harvard Medical School in Boston compared the quality of care given to both patients covered by Medicaid, those covered by other managed care programs and those covered by both. He evaluated the care given for such procedures as breast cancer screening, chronic disease management and care or pregnant women. He found that care given to those covered under other commerical managed care programs exceeded the quality of care given to those covered by Medicaid in all areas except for one: screening for chlamydia.

Under a section called “Improving the Quality of Medicaid for Patients and Providers,” the Patient Protection and Affordable Care Act calls for the development of a core set of health quality measures. These health measures are intended for both providers and states to oversee and ensure the kind of care adults enrolled in Medicaid, in particular, are receiving. (There is a separate set of quality measures for children). The list of measures is not designed as a static thing. Rather, the development of the measures calls for cooperation between several entities and experts in the Medicaid and medical world, as well as continuing input and research. These measures include such medical procedures as flu shots, breast and cervical cancer screenings, and long- and short-term complications from diabetes (which fall under a heading entitled “Prevention and Health Promotion”), as well as controlling high blood pressure and antidepressant medication management (under “Management of Chronic Conditions”). In total, there are 51 measures initially suggested. Some other categories the measures fall under include “Management of Acute Conditions,” “Family Experiences of Care” and “Availability.” (To view a complete list of measures, visit

This initial list of measures was proposed by a subcommittee created by the National Advisory Council of the Agency of Healthcare Research and Quality. The subcommittee consisted of state Medicaid representatives, health care quality experts, representatives of health professional organizations and associations. The list was developed by reviewing measures from nationally-recognized sources, such as the National Quality Forum. They also split into four work groups, including: maternal/reproductive health, overall adult health, complex health care needs and mental health and substance use. From about 1,000 potential measures, the subcommittee narrowed the list down to 51.

However, this is only the initial list. The bill called for the list to first be published by January of this year so that citizens and medical agencies were able to provide feedback on it. After considering the feedback, and consulting with states, the secretary will publish the core set of health quality measures for Medicaid-eligible adults. By January 2013, the secretary in consultation with the states, will develop a standardized format for reporting information based on the initial core set of adult health quality measures. The secretary and states will also create procedures to encourage states to use these measures to voluntarily report information regarding the quality of care for Medicaid-eligible adults. The bill also calls for the list to reviewed and possibly changed annually. This approach ensures not only that adults will receive quality care, but relevant care as medicine evolves. It also provides a way to fix problems found in the system.

The subcommittee is currently looking for feedback on these quality measures. In an article posted online by the Federal Register (the daily journal of the U.S. government), the group indicates its looking for input on what measures should be added, and what should be deleted, as well as the feasibility of measuring some of the procedures.

“We are trying to strike a balance between the need for State data to monitor and improve quality and an interest in minimizing the reporting burden on States and providers by aligning with other quality reporting and incentive initiatives,” the article reads.

Once the list is finalized and published, the Secretary of Health and Human Services will create a Medicaid Quality Program. This program will develop, test and validate emerging evidence-based measures. Within two years of its creation and annually thereafter, the secretary will publish recommended changes to the list of measures based on the results of studies completed by the Medicaid Quality Program.

All in all, if the program works the way its supposed to, these changes sound like an excellent way to stay on top of what kind of care Medicaid enrollees are receiving. It also provides an opportunity for those involved to weigh in on what’s being measured.

Mary Ann Heath has been reading and blogging about the Patient Protection and Affordable Care Act since January. Her goal is to read all 906 pages of the bill in one year.


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