3 Tips for States Considering a Medicaid and CHIP Quality Rating System

As we mark National Health Care Quality Week, we are reminded of the upcoming—and important—quality-related changes that will occur within the Medicaid and Children’s Health Insurance Program (CHIP) space. States will soon need to implement a Quality Rating System, or QRS, to provide transparent and easily understandable information on the performance of their Medicaid and CHIP managed care plans.

While health care quality ratings and health plan comparison websites may be familiar to individuals with Medicare, employer-sponsored insurance, or Affordable Care Act coverage, these are new concepts for many states and Medicaid/CHIP enrollees. These new requirements are intended to raise the bar for quality reporting for state Medicaid and CHIP managed care programs, providing guidelines for monitoring the quality of care that children and adults receive.  Ultimately, the goal is to ensure each person benefits from high quality, evidence-based care and receives good health outcomes.  Each Medicaid and CHIP QRS will provide actionable information for states, providers, and beneficiaries, including comparative data on 22 nationally validated health care measures and overall ratings for each Medicaid and CHIP health plan. Millions of beneficiaries and their caregivers will be able to use this information to inform their selection of a managed care plan. By increasing transparency and the availability of performance and quality information, the Medicaid and CHIP QRS should incentivize improvements in plan performance and promote accountability, thereby increasing the quality and timeliness of services that beneficiaries receive.  

States will have several years to implement the new rating systems and develop consumer websites. However, not all states currently collect and report on the measures that will be included in the QRS; only a dozen states have experience operating a managed care rating system for Medicaid. Abt Global, having designed the Nursing Home Compare rating system, has a deep understanding of health care quality rating systems—arguably, we’ve helped shape the evolution of these patient-focused tools. Our team maintains the Nursing Home Compare rating algorithm and delivers monthly ratings and individual provider preview reports for more than 15,000 nursing homes on tight timelines and with complete accuracy. Through our experience working with the Centers for Medicare & Medicaid Services (CMS) over the past 15 years to develop and implement this rating tool, we’ve learned a lot about the challenges, opportunities, and considerations that states might face in implementing their own quality rating systems, and thus have some tips to share.

Tips for States

1. Input from beneficiaries, their caregivers, and states should be central to the design and implementation of the QRS. Beneficiaries may consider a number of varying factors when selecting a health plan, so it will be important for states to develop a rating system that makes performance differences among health plans clear. For example, the use of human-centered design techniques will result in a process that incorporates the development of personas, user journey mapping, and user prototypes to produce a QRS website display that contains meaningful information that is digestible and useful to Medicaid and CHIP beneficiaries.
2. Implementation and oversight of the QRS requires the coordination of various time-sensitive activities, including data collection, validation, rating calculation, and website development. States will need a data integration and management plan specific to this activity to mitigate risks and complete the necessary milestones on schedule. To do so, we’d suggest drafting a plan that details critical pathways to the system’s production milestones (with associated dates), outlines any anticipated issues and potential risks, and clearly identifies dependencies associated with the execution of each milestone.
3. Each QRS website must meet a variety of technical and accessibility specifications while also taking into account the unique and varied health literacy of Medicaid and CHIP beneficiaries. All sites should be easily accessible, navigable, and readable while addressing complex health care topics.

Health Care Quality Week gives us and our colleagues a chance to remind ourselves that quality spans a continuum, from systems to execution to outcomes that impact our friends, families and neighbors. The Medicaid and CHIP QRS is part of a comprehensive strategy that states, the federal government, beneficiaries and other stakeholders have been building to support quality as a means of meeting broader Medicaid and CHIP goals, such as advancing equity, expanding access to quality care, and promoting value-based, person-centered care. Abt shares these goals--part of the reason why we work at Abt is to improve health care outcomes for everyone, every day. If you think we can help enhance the quality of your system, please don’t hesitate to reach out.