The Business Case for Quality, Phase II (BCQ II) sought to develop targeted, rigorous, and actionable evidence on improvements in the quality of care and the return on investment (ROI) that may be generated to multiple stakeholders if financial incentives are aligned and health care delivery changed to improve care for Medicaid beneficiaries with chronic medical conditions-in this case, children with asthma. BCQ II was sponsored by CHCS and funded by the Robert Wood Johnson Foundation and The Commonwealth Fund. Based on a competitive process, three grantees were selected to participate.

Grantees’ success at achieving the goals of improving quality of care and demonstrating a business case for quality was mixed. Although implementation was successful, the grantees did not achieve a positive ROI during the intervention period. Collectively, these findings demonstrate that achieving a business case is difficult, particularly for newly established interventions, with their unanticipated challenges, their need to implement process improvements, and the time required for improvements to affect health care use and produce financial gains.

BCQ II provides lessons for health care agencies and organizations that wish to implement quality improvement programs for pediatric asthma and for policymakers wishing to better align incentives to reward quality. Lessons include considering ROI during program design, targeting the appropriate populations, identifying potential challenges proactively, engaging providers and patients, monitoring performance, and managing expectations.

This report outlines evaluation findings for the three BCQ II grantees. It also provides conclusions and examines the implications of BCQ II for policymakers and other organizations wishing to implement programs that improve quality while providing a financial return. Case studies provide an in-depth look at each grantee intervention. Each case study includes: (1) a detailed description of the intervention and the ways it sought to correct financing misalignments; (2) a presentation of evaluation findings; and (3) a discussion of their implications for other organizations wishing to implement similar initiatives. Finally, an appendix provides detailed information about the evaluation methodology.