Using Data to Promote Quality of Care Under Medicaid Transformation

Blog | November 27, 2018


By Berkeley Yorkery


In 2015, the North Carolina General Assembly passed a law requiring the new Medicaid delivery system and Prepaid Health Plan contracts to be “built on defined measures and goals” for “health outcomes, quality of care, patient satisfaction, access, and cost.” In 2016, the North Carolina Institute of Medicine, in partnership with the North Carolina Division of Health Benefits (NCDHB), convened a task force to meet this challenge. The Task Force on Health Care Analytics set out to recommend a concise set of metrics for driving improvement in population health under Medicaid Transformation. These metrics will now be used by NCDHB to hold Prepaid Health Plans accountable for the health and well-being of enrollees, and by Prepaid Health Plans to identify areas for quality improvement work.



The Task Force


The Task Force considered process and outcome metrics (e.g. infant mortality and the percentage of people receiving required and recommended immunizations) across a broad spectrum of health care, care settings, and populations, including but not limited to public health, population health, whole-person health pediatrics, oral health, key high-cost high-risk subpopulations, mothers and infants, those with chronic illnesses and foster children. It also considered areas of health disparities, including racial and ethnic disparities and disparities between rural and urban areas.


The recommended metrics address North Carolina's most significant health priorities and are aligned as much as possible with national Medicaid measures and those of other insurers. In addition, because of the large proportion of North Carolina’s Medicaid population who are children (approximately 50%), the Task Force sought to identify cross-cutting measures that would be applicable to both pediatric and adult Medicaid beneficiaries.



What’s Next


Under Medicaid Transformation, the NCDBH will contract with Prepaid Health Plans to provide managed care services to most beneficiaries. The Prepaid Health Plans will be required to track and report 48 quality metrics, most of which were recommended by the Task Force [1]. Metrics track use of preventive services, appropriate clinical treatments, intermediate and outcome measures, cost and utilization measures and specific measures on behavioral health treatment [2]. Prepaid Health Plans will be required to report the metrics stratified by certain criteria, including age, race/ethnicity and gender in order to identify any disparities.


In addition to evaluating Prepaid Health Plans’ performance based on the quality metrics, the NCDBH will also require them to identify and implement three performance improvement projects during the course of their contract, then provide quality improvement support to their network providers around the selected performance metrics [3].


Tracking quality measures is critical to ensuring that Medicaid beneficiaries continue to receive high-quality care as North Carolina’s Medicaid program moves to integrate Prepaid Health Plans.




[1], section vii.e.

[2] Silberman P.  Presentation to the Sheps Center on Health Services Research.  Nov. 7, 2018.

[3] Ibid.