How states can utilize quality measurement to reduce health disparities

Social determinants of health (SDOH) such as race, ethnicity, income, socioeconomic status, education, physical environment, and other factors play an indisputable role in accessing and receiving quality health care. Over 40% of individuals enrolled in Medicaid or in the Children’s Health Insurance Program (CHIP) in 2018 had family incomes below 100% of the federal poverty level, and more than half of enrollees identified as Black, Hispanic, or another non-White race or ethnicity.

State Medicaid programs and Medicaid managed care organizations (MCOs) are in a unique position to advance health equity by ensuring the people they serve are receiving high-quality care and have access to social services systems. However, there is currently no standard framework around health equity measurement and reporting for state Medicaid agencies to utilize, making it difficult to assess what aspects of care need to be improved and hold organizations accountable for providing their members with quality health care.

Current challenges to overcome

There are many barriers that need to be addressed in order for Medicaid agencies to best utilize quality measures and improve health equity. The quality of the data and the collection methods used is important to ensure data is both accurate and complete. Members may be hesitant to provide their personal information due to fears of discrimination or security breaches. Additionally, Medicaid agencies don’t always have clear guidelines and best practices for storing and sharing sociodemographic and social needs-related data. These factors, and others, can lead to potential gaps in collecting complete, accurate information on members’ health and wellbeing.

Fortunately, there are several strategies state health care agencies can employ to overcome challenges and help eliminate health disparities:

• Recognize where inequities exist and identify the most impacted populations. It is critical that states identify focus areas and the priority populations who are likely to experience inequities, such as certain racial and ethnic groups or those with chronic conditions or disabilities. As reported in a 2021 NCQA white paper, maternal and child health and behavioral health were also areas of frequent focus in state equity strategies. Taking a targeted approach to addressing inequities among these and other populations can help prevent the unintended exacerbation of health disparities.
• Engage with and listen to stakeholders. When putting new programs in place, it is important to first receive input and buy-in from those that will be affected. Potential stakeholders include patient and community advocates, patient organizations, community-based organizations, providers, and plan representatives. Examples of ways to receive input include hosting public town hall meetings, convening public comment periods, including community members in decision-making processes, and working with beneficiary advisory committees to seek feedback.
• Consider different approaches. Focusing only on disparities may miss measure concepts targeting unmet social risks, needs, and patient experience and outcomes data which are vital for tackling underlying concerns affecting members’ health and care. The measurement approaches which states currently use generally fall into four different categories. The first is a stratification of existing process, outcome, and experience measures, such as the clinical measure of poor control of Hemoglobin A1C, which has evidence of being impacted by disparities. An increasing number of states evaluate performance on quality measures by equity-targeted stratification (e.g., race, ethnicity, gender, rurality). The second is a direct measure of social needs or SDOH such proportion of members screened for unmet needs. The third, a summary index approach, aims to combine performance on multiple quality measures, such as the Health Equity Summary Score developed through the CMS Office of Minority Health. The fourth includes measures of community wellbeing or lack thereof, which incorporate and summarize broader environmental, socioeconomic, health, and social indicators at levels above the individual level.
• Create clear accountability benchmarks. States may take different approaches to measurement and quality improvement strategies they use around health equity, but every state should determine how it will measure performance of MCOs. For example, in Louisiana, the state measures managed care plan performance and holds plans accountable for reducing identified disparities. When Medicaid MCOs perform below expectations, the state of Louisiana may withhold 1% of the reimbursement for care provided to Medicaid enrollees.

Medicaid agencies can demonstrate their commitment to achieving health equity, but clear measurement strategies will be needed to balance states’ goals with challenges related to data quality and measurement burden.

Kristine Thurston Toppe is Assistant Vice President of State Affairs at the National Committee for Quality Assurance (NCQA) and Rachel Harrington, PhD, is a Research Scientist at NCQA. NCQA is a private, nonprofit organization dedicated to improving health care quality.