The desire to improve quality is a key platform of state agendas for healthcare transformation. The quality of care delivered to Medicaid beneficiaries is a central element in obtaining value and controlling costs, as well as directly affecting the lives of beneficiaries. Poor-quality care contributes to increased costs due to unnecessary hospitalizations and readmissions, higher intensity and volume of care, and rework. More importantly, it affects the health and lives of individuals in terms of mortality, pain and suffering, and productivity.
Improving the quality of healthcare in the United States is a shared goal of government and commercial payers, plans, providers, advocates, researchers and consumers. It is a multifaceted challenge requiring the participation of all stakeholders in the system and absolute commitment to constant improvement. We need research to understand what works and for whom; we need communication tools to help providers utilize that information at the point of care; we need consumers to demand and use quality data as they seek and receive care; we need payers to demand and reward quality care; and we need regulatory, legal and reporting systems that identify and respond to neglect, abuse and poor care.
Medicaid agencies have special responsibilities in this system as they reimburse and organize care on behalf of some of the most medically vulnerable patients in our country. Putting quality-management processes to work requires specialized resources and capabilities and creates challenges for any organization. Quality-management in Medicaid programs faces additional challenges due to the range and depth of their beneficiary population’s needs and the help they need to navigate and access an extraordinarily complex healthcare delivery system.
The Centers for Medicare & Medicaid Services (CMS) have attempted to address these challenges in a number of ways, including the creation of a broad national quality framework, the provision of technical assistance services, and the development of standard tools and templates. The External Quality Review function is a key element in CMS’ approach and creates important opportunities for states. HP has prepared this paper to summarize those opportunities and highlight certain best practices that state Medicaid agencies may wish to consider in developing their quality-management programs.