Health care quality has been a concern for policymakers since the Institute of Medicine published two landmark reports nearly two decades ago: To Err is Human, on patient safety, and Crossing the Quality Chasm, on gaps in quality in the United States health care system. Since then, quality measurement has become a must-have foundational element in numerous health care reforms, including accountable care organizations (ACOs).
Yet tracking quality metrics comes with a cost. ACOs are often subject to competing quality reporting requirements from different payer types (such as Medicaid, Medicare, and commercial payers), as well as different individual payers (such as competing managed care organizations in the same market). Inconsistent performance metrics from a variety of payers create significant administrative burdens for ACO providers and may detract from providers’ intrinsic motivation to provide effective care. It may also dilute the level of effort that ACO providers exert to improve quality of care and outcomes.
The variety of delivery system reform initiatives being undertaken by payers simultaneously—ACOs, patient centered medical homes (PCMHs), and health homes, for example—can compound this problem, as each program often requires separate quality measurement sets. If measures are not aligned, there may be an incentive for providers to limit their participation in multiple reform programs, since participation has an implicit administrative cost.
Several states that participated in the CHCS Medicaid ACO Learning Collaborative, supported by The Commonwealth Fund, have aligned their Medicaid ACO quality measures with related health reform efforts to avoid too many competing measurement requirements. When deciding how to align quality metrics, states should focus on: (1) the purpose of the quality metrics; (2) whether they have found the right balance between administrative burden and measurement; and (3) if the measures promote accountability and truly measure program success. While quality metrics likely cannot be completely aligned—ACOs serving the Medicare population, for example, have certain goals that other programs, such as health homes, do not share—states have attempted to strike the balance between quality measurement and provider flexibility for their Medicaid ACOs:
- Vermont introduced its Medicaid Shared Savings Program (SSP), the state’s Medicaid ACO program, at the same time that the state’s Green Mountain Care Board introduced commercial ACOs. To reduce the burden on providers and payers, the state aligned the performance metrics for the Medicaid SSP, with commercial ACO and Medicare Shared Savings Program (MSSP) metrics where possible. While the programs cover populations with different health care needs, Vermont uses 10 identical metrics for its Medicaid and Medicare SSP, and six of the seven core measures used for Vermont’s commercial ACOs are shared by the Medicaid SSP. This alignment seems to be effective at encouraging multi-payer arrangements, as Vermont’s two Medicaid ACOs, One Care Vermont and Community Health Accountable Care, are also Medicare Shared Savings Program ACOs and have formed commercial ACO arrangements.
- Minnesota’s Health Care Homes program, the state’s PCMH model, is closely linked to its Integrated Health Partnerships (IHP) program. The Health Care Homes and IHP programs share quality metrics, including four of five IHP clinical quality measures. In addition, the state attributes patients to its IHPs by first looking at whether the patient is part of a Health Care Home, and if that Health Care Home is part of an IHP, the patient is attributed to the IHP.
- Iowa’s private health insurance market is highly concentrated, with one major player, Wellmark, holding 84 percent of the state’s insurance market. To encourage alignment between the commercial and Medicaid ACO programs, the state chose the same set of quality metrics for its ACO program for the Medicaid expansion population that Wellmark uses in its commercial lines, the 3M Value Index Score (VIS). Currently, the VIS is used by Wellmark’s commercial ACOs, Iowa’s Medicaid ACOs, and Iowa Medicaid’s Medical Home Bonus payment program.
- New Jersey’s Medicaid ACO Pilot Program requires ACOs to report on 21 core measures, almost half of which align with MSSP metrics. The state requires ACOs to choose six “voluntary” metrics from a list of potential metrics – giving ACOs the opportunity to select metrics that align with other programs. Many of the voluntary measures align with the MSSP as well.
Alignment of quality metrics gives states an opportunity to target the particular health needs of their populations without imposing the additional burden that new, separate quality measures might impose. As more states join those in the Medicaid ACO landscape, they have the opportunity to align their metrics with existing programs and payers to improve their state health care programs.