California would benefit from a common yardstick to measure Medicaid performance
This post was produced for the USC Health Data Accountability Project, a joint initiative of the USC Center for Health Journalism and the Gehr Family Center for Health Systems Science.
Medicaid, the state-federal safety net health program for low-income people, now covers more than one in three Californians — about 13.3 million people in 2017 — an increase of almost 4 million since the Affordable Care Act. Many enrollees in Medi-Cal, California’s Medicaid program, are among the state’s most vulnerable residents, including nearly 2 million seniors and people with disabilities and more than 5.5 million children, including foster kids and young adults.
According to IHA’s Cost & Quality Atlas, quality of care varies widely across California counties in Medi-Cal, Medicare, and commercial insurance alike. Extensive information is publicly available on how providers measure up for their commercial and Medicare populations, which is needed for performance improvement. However, similar information regarding provider performance for Medi-Cal is lacking.
As Medi-Cal enrollment continues to grow, IHA believes there is a growing imperative to create a common yardstick to more easily gauge provider performance. Common measurement of medical group quality through a standardized report card could serve as the foundation for health plan payment incentives to providers. Making that report card public would provide an incentive for performance improvements, as is already the case for commercial HMO and Medicare Advantage populations. Common measurement, benchmarking and incentive design would send a strong signal to plans and providers on where to target performance improvement efforts.
In 2014, 16 Medi-Cal health plans had pay-for-performance programs in place. Unfortunately, measurement programs varied so much that it was difficult to make comparisons — more than 80 performance measures were used, with only one measure in common across plan programs. That is challenging for providers and enrollees alike, and IHA is trying to bring the same standardization to Medi-Cal as has existed for commercial plans since the early 2000s. This not only is common sense, but now many Medi-Cal enrollees, in Southern California especially, get care through the same provider organizations caring for commercial and Medicare Advantage HMO enrollees.
Of the 13.3 million Medi-Cal enrollees in California, more than 83 percent of patients now get their care through managed-care plans. IHA has focused on that population, and targeted Medi-Cal health plans that offer pay-for-performance rewards for quality, because those plans already had taken the initial steps to build quality measurement into their operations.
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As a start and building on commercial and Medicare quality initiatives, IHA has been working with the state of California Department of Health Care Services, health plans and providers to develop and implement a voluntary and standardized Medi-Cal measure set. The resulting common measure set includes 10 clinical quality measures that address Medi-Cal priority areas, including chronic diseases such as diabetes care, as well as maternity care, and prevention.
The goal: to simplify and streamline so that providers, health plans and regulators could easily compare performance based on a shared set of metrics.
As of 2017, five Medi-Cal plans had fully adopted the common set of 10 clinical quality measures. Another nine had partially adopted the core measures, and four others planned to adopt the measure set in 2018. These plans will provide performance incentives for their Medi-Cal providers based on the common measures. A further step could be to collect the results of the common measures and make them publicly available. Provider incentives and public reporting will facilitate high-quality care for all patients, whether they receive insurance from Medi-Cal, Medicare, or commercial insurers.
In addition, IHA is now opening its commercial HMO program to Medi-Cal plans, so that providers serving both commercial and Medi-Cal members are working with a common program design and a common measure set. To date, Care1st Health Plan in Los Angeles is participating.
Finally, IHA also recently launched an effort to standardize performance measurement for the growing number of accountable care organizations (ACO) in California serving commercial members, which encourage physicians, hospitals and other providers to work together and be accountable for both the quality and cost of care of health plan enrollees. Many of the Medi-Cal common measures are included in the ACO measure set to send a clear signal and minimize measurement burden for providers that serve multiple lines of business.
We still have work to do when it comes to measuring, reporting, and improving quality in Medi-Cal. By virtue of its size and role in serving the most vulnerable people among us, Medi-Cal is simply too big to leave behind in the move toward better care, better health and smarter spending for all Californians.
Jeff Rideout, M.D., is the president and CEO of the Integrated Healthcare Association.
[Photo by Marco Verch via Flickr.]