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Medicaid Program: Initial Core Set of Health Quality Measures for Medicaid-Eligible Adults

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Office of the Secretary, HHS.


Notice with comment period.


This notice identifies an initial core set of health quality measures recommended for Medicaid-eligible adults, as required by section 2701 of the Affordable Care Act, for voluntary use by State programs administered under title XIX of the Social Security Act (the Act), health insurance issuers and managed care entities that enter into contracts with Medicaid, and providers of items and services under these programs. This notice also solicits comments on these initial measures, on facilitating the use of these measures by States and on identifying priority areas for measure enhancement and development.


To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on March 1, 2011.


Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of two ways (please choose only one of the ways listed):

1. Electronic Mail.

2. Regular Mail. Agency for Healthcare Research and Quality, Attention: Nancy Wilson, Immediate Office of the Director, Room 3028, 540 Gaither Road, Rockville, MD 20850.

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Nancy Wilson, M.D., M.P.H., Coordinator of the Advisory Council Subcommittee, at the Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, (301) 427-1310. For press-related information, please contact Karen Migdail at (301) 427-1855.

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I. Background

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (Affordable Care Act) (Pub. L. 111-148). Section 2701 of the Affordable Care Act added new section 1139B to the Social Security Act (the Act); section 1139B(a) of the Act now mandates that the Secretary of Health and Human Services (HHS) identify and publish for public comment a recommended initial core set of health quality measures for Medicaid eligible adults. Section 1139B(b) of the Act, as added by section 2701 of the Affordable Care Act, requires that a recommended initial core set be published for public comment by January 1, 2011, and that an initial core set be published by January 1, 2012.

In addition, the Affordable Care Act mandates that HHS should complete the following actions

—By January 1, 2012:

  • Establish a Medicaid Quality Measurement Program to fund development, testing, and validation of emerging and innovative evidence-based measures.

—By January 1, 2013:

  • Develop a standardized reporting format on the core set and procedures to encourage voluntary reporting by the States.

—By January 1, 2014:

  • Annually publish recommended changes to the initial core set that shall reflect the results of the testing, validation, and consensus process for the development of adult health quality measures.

—By September 30, 2014:

  • Collect, analyze, and make publicly available the information reported by the States as required in section 1139B(d)(1) of the Act.

Additionally, the statute requires the initial core set recommendation to consist of existing adult health quality measures that are in use under public and privately sponsored health care coverage arrangements or are part of reporting systems that measure both the presence and duration of health insurance coverage over time and that may be applicable to Medicaid-eligible adults.

II. Method for Determining Proposed Initial Core Set of Adult Health Quality Measures

The Affordable Care Act parallels the requirement under title IV of the Children's Health Insurance Program Reauthorization Act (Pub. L. 111-3) to identify and publish a recommended initial core set of quality measures for children in Medicaid and the Children's Health Insurance Program. A similar process was used to identify the proposed initial core set of adult health quality measures. To facilitate an evidence-based and transparent process for making recommendations, the National Advisory Council of the Agency for Healthcare Research and Quality (AHRQ) created a subcommittee (the Subcommittee) for identifying quality measures for Medicaid-eligible adults. The Subcommittee consisted of State Medicaid representatives, health care quality experts, and representatives of health professional organizations and associations. The Subcommittee held a public meeting October 18th and 19th and considered public comments. The Subcommittee's advice was reported to the Chair of AHRQ's National Advisory Council and considered further by the Centers for Medicare & Medicaid Services (CMS) and staff in the Office of the Secretary of HHS prior to this public posting.

The initial core set was developed by reviewing measures from nationally recognized sources, including measures currently endorsed by the National Quality Forum (NQF), measures submitted by Medicaid medical directors, measures currently in use by CMS, and measures suggested by the Co-Chairs and members of the Subcommittee of AHRQ's National Advisory Council.

In prioritizing measures, the Subcommittee considered the needs of adults (ages 18 and older) enrolled in Medicaid. To help guide the discussion of priority health needs within the adult populations covered by Medicaid, the Subcommittee was divided into four workgroups—Maternal/Reproductive Health, Overall Adult Health, Complex Health Care Needs, and Mental Health and Substance Use. The workgroups considered potential measurement opportunities across the Institute of Medicine's (IOM) eight domains of quality: Safe, timely, effective, efficient, access, patient and family centeredness, care coordination, and infrastructure capabilities for health care. The Subcommittee also considered how health care equity and value (also from the IOM) could be reflected in the initial measurement set. Ultimately, the Subcommittee used the following three criteria in voting on the recommended measures for the core set:

  • The scientific acceptability of measure properties.
  • Feasibility of use by Medicaid.
  • Importance to Medicaid programs.

The Subcommittee also considered whether the measures were currently used in other Medicaid quality Start Printed Page 82398measurement efforts (for example, three maternity care measures included in the initial core set of children's quality measures, and measures designated for inclusion in the Medicare and Medicaid Electronic Health Record Incentive Payment Programs). The Subcommittee identified many measures that were cross-cutting and relevant to the entire adult Medicaid population. In the end, the Subcommittee identified a set of 51 measures to recommend as the initial core set of adult quality measures.

We are now soliciting public comments on the recommended initial core set of adult quality measures. Specifically, we seek comment on whether any measures should be added or deleted from the initial core set, the reporting burden, which measures may need further development, and the types of technical assistance and other resources States may need to implement these measures. We also are interested in feedback on how many measures are feasible and realistic for a State to collect and use in its monitoring of quality of care. We are trying to strike a balance between the need for State data to monitor and improve quality and an interest in minimizing the reporting burden on States and providers by aligning with other quality reporting and incentive initiatives.

HHS will be making improvements and enhancements to the core set as a result of public comments on the initial recommended core measure set. To further these efforts, AHRQ and CMS are working to identify ways to align State reporting requirements with other HHS quality reporting initiatives and requirements; coordinate quality measurement efforts with payment reform strategies, health information technology, and electronic health record initiatives; and identify priority areas for the development of new measures. States will also receive technical assistance to facilitate implementation of the measures. The initial core set of adult quality measures, as required by the Affordable Care Act, will serve as the groundwork for creating a standardized approach to better understand the quality of care adults in Medicaid receive, improve how this care is measured, and create opportunities to impact health outcomes.

III. The Draft Initial Core Set of Health Quality Measures for Medicaid-Eligible Adults

The list of measures in the accompanying table of measures was developed on the basis of advice from the Subcommittee. For additional information, see the background paper at​.

Respondents commenting on the measurement set are encouraged to:

  • Specify which of the measures are being addressed.
  • Explain the reasoning behind their comment.

In addition, we invite comments on ways to enhance the initial core set of measures so they can be implemented efficiently and accurately across all Medicaid programs, providers, and enrollees.

IV. Collection of Information Requirements

This document does not impose information collection and record-keeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35).

V. Regulatory Impact Statement

In accordance with the provisions of Executive Order 12866, this notice was reviewed by the Office of Management and Budget.

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Authority: Sections XIX and XXI of the Social Security Act (42 U.S.C. 13206 through 9a).

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Dated: November 17, 2010.

Donald M. Berwick,

Administrator, Centers for Medicare & Medicaid Services.

Approved: December 20, 2010.

Kathleen Sebelius,

Secretary, Health and Human Services.

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Measures Recommended for Initial Core Set of Health Quality Measures for Medicaid-Eligible Adults

This table of the recommended initial core measure set includes National Quality Forum (NQF) identifying numbers for measures that have been endorsed, provides the measure owners, and indicates those measures that have been designated for inclusion in the Medicare & Medicaid Electronic Health Record Incentive Payment Programs for eligible health care professionals and hospitals that adopt certified Electronic Health Record technology under the Final Rule published in the July 28, 2010 Federal Register (75 FR 44314).

NumberNQF ID†Measure ownerMeasure nameEHR ‡
Prevention & Health Promotion
10039NCQAFlu Shots for Adults Ages 50-64 (Collected as part of HEDIS CAHPS Supplemental Survey)
20421CMSAdult Weight Screening and Follow upX
30031NCQABreast Cancer ScreeningX
40032NCQACervical Cancer ScreeningX
5NARANDAlcohol Misuse: Screening, Brief Intervention, Referral for Treatment
60027NCQAMedical Assistance With Smoking and Tobacco Use CessationX
70418CMSScreening for Clinical Depression and Followup Plan
8NANCQAPlan All-Cause Readmission.
90272AHRQPQI 01: Diabetes, short-term complications
100273AHRQPQI 02: Perforated appendicitis.
110274AHRQPQI 03: Diabetes, long-term complications
120275AHRQPQI 05: Chronic obstructive pulmonary disease
130276AHRQPQI 07: Hypertension.
140277AHRQPQI 08: Congestive heart failure.
150280AHRQPQI 10: Dehydration
160279AHRQPQI 11: Bacterial pneumonia
170281AHRQPQI 12: Urinary Tract Infection Admission Rate
180282AHRQPQI 13: Angina without procedure.
190638AHRQPQI 14: Uncontrolled Diabetes Admission Rate
200283AHRQPQI 15: Adult asthma.
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210285AHRQPQI 16: Lower extremity amputations among patients with diabetes
Management of Acute Conditions
220052NCQAUse of Imaging Studies for Low Back PainX
230640TJCHBIPS—2 Hours of physical restraint use.
240576NCQAFollowup After Hospitalization for Mental Illness
250476Providence St. Vincent Medical CenterAppropriate Use of Antenatal Steroids.
260469Hospital Corporation of AmericaElective delivery prior to 39 completed weeks gestation
270648AMA-PCPITimely Transmission of Transition Record (Inpatient Discharges to Home/Self-Care or Any Other Site of Care)
280647AMA-PCPITransition Record With Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self-Care or Any Other Site of Care)
Management of Chronic Conditions
290071NCQAPersistence of Beta-Blocker Treatment After a Heart Attack
300018NCQAControlling High Blood PressureX
310074AMA-PCPICoronary Artery Disease (CAD): Drug Therapy for Lowering LDL CholesterolX
320075NCQAComprehensive Ischemic Vascular Disease Care: Complete Lipid Profile and LDL-C Control RatesX
330063NCQADiabetes: Lipid profile.
340057NCQAComprehensive Diabetes Care: Hemoglobin A1c testing
350036NCQAUse of Appropriate Medications for People With AsthmaX
360403NCQAHIV/AIDS: Medical visit.
370105NCQAAntidepressant Medication ManagementX
38NARANDBipolar I Disorder 2: Annual assessment of weight or BMI, glycemic control, and lipids
39NARANDBipolar I Disorder C: Proportion of patients with bipolar I disorder treated with mood stabilizer medications during the course of bipolar I disorder treatment
40NARANDSchizophrenia 2: Annual assessment of weight/BMI, glycemic control, lipids
41NARANDSchizophrenia B: Proportion of schizophrenia patients with long-term utilization of antipsychotic medications
42NARANDSchizophrenia C: Proportion of selected schizophrenia patients with antipsychotic polypharmacy utilization
430021NCQAAnnual Monitoring for Patients on Persistent Medications
440541PQAProportion of Days Covered (PDC): 5 Rates by Therapeutic Category
Family Experiences of Care
450006AHRQCAHPS Health Plan Survey v 4.0—Adult Questionnaire
460007NCQACAHPS Health Plan Survey v 4.0H—NCQA Supplemental items for CAHPS 4.0 Adult Questionnaire
47NANCQAAmbulatory Care: Outpatient and Emergency Department Visits
48NANCQAInpatient Utilization: General Hospital/Acute Care
490004NCQAInitiation and Engagement of Alcohol and Other Drug Dependence TreatmentX
50NANCQAMental Health Utilization.
51NANCQAPrenatal and Postpartum Care: Postpartum Care Rate
† NQF ID National Quality Forum identification numbers are used for measures that are NQF-endorsed; otherwise, NA is used.
‡ EHR Measures with an “X” are included in the Medicare and Medicaid Electronic Health Record Incentive Payment Program and may be collected through electronic health records. Specifications for these measures are available from the Centers for Medicare & Medicaid Services Web site at:​QualityMeasures/​03_​ElectronicSpecifications.asp#TopOfPage.
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[FR Doc. 2010-32978 Filed 12-29-10; 8:45 am]