Quality Measure Development: Dual Enrollees, Managed Long-Term Services and Supports, and Medicaid Innovation Accelerator Programs

2015-2017
Prepared for
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Center for Clinical Standards and Quality

More Americans now receive health coverage through Medicaid or the Children’s Health Insurance Program (CHIP) than any other source of insurance; in 2015, approximately 72 million Americans were enrolled in these programs according to The Centers for Medicare & Medicaid Services (CMS). Mathematica is developing reliable and valid quality measures for certain groups of people enrolled in Medicaid who have the highest costs and greatest needs for health care and social support. These measures will address critical gaps in quality measures for:

  • People eligible for both Medicare and Medicaid, sometimes referred to as “dual enrollees”
  • People with disabilities and older adults receiving long-term services and supports (LTSS) in institutions or home- and community-based settings through managed care organizations
  • People with substance use disorders, mental illness, or other complex conditions that lead to high use of emergency room visits, and hospital admissions or readmissions

Many quality measures already exist for specific services delivered by these programs. But there are few measures that capture the outcomes of care, particularly from the patient or beneficiary perspective. The measure domains expected to be developed include those concerning care coordination, beneficiary experience of care, effective transitions across care settings, quality of life and community integration for people with disabilities, use of preventive services, management of behavioral health problems, and avoidance of unnecessary emergency room visits and hospital and nursing home admissions.   

Mathematica is joined in this effort by Brandeis University and the National Committee for Quality Assurance. The measure development process will build on prior and current work of the National Quality Forum and include multiple opportunities for stakeholder engagement and feedback. Updates on current project activities are provided below.

CMS Public Comment Period for Proposed Quality Measures:

  • Duals-2: Healthy Days in the Community–Submit comments by April 21, 2017
  • Duals-12: Non-Acute Mental Health Services Utilization–Submit comments by April 27, 2017
  • SUD-4: Use of pharmacotherapy for opioid use disorder (OUD)–Submit comments by May 10, 2017
  • BCN-2: All-cause inpatient admission rate for Medicaid beneficiaries with complex care needs and high costs (BCNs)–Submit comments by May 12, 2017
  • PMH-10: Stratification for Medicaid Beneficiaries with Serious Mental Illness: Proportion of Days Covered: 3 Rates by Therapeutic Category–Submit comments by June 9, 2017

Please contact MedicaidQualMeasures@mathematica-mpr.com with any questions.