Recommendations for Improving the Core Sets of Health Care Quality Measures for Medicaid and CHIP: Summary of a Multistakeholder Review of the 2020 Child and Adult Core Sets

Recommendations for Improving the

Core Sets of Health Care Quality Measures

for Medicaid and CHIP

Summary of a Multistakeholder Review of the 2020 Child

and Adult Core Sets

Final Report

August 2019

2020 CHILD AND ADULT CORE SET STAKEHOLDER

WORKGROUP MEMBERS

Voting Members (Affiliation as of May 2019)

Gretchen Hammer, MPH, Co-chair

Public Leadership Consulting Group

David Kroll, MD

Department of Psychiatry, Brigham Health, Harvard Medical

School

David Kelley, MD, MPA, Co-chair

Pennsylvania Department of Human Services

Carolyn Langer, MD, JD, MPH

Fallon Health

Richard Antonelli, MD, MS

Boston Children’s Hospital

Lauren Lemieux

American College of Obstetricians and Gynecologists

Jill Arnold

Maternal Safety Foundation

Jill Morrow-Gorton, MD, MBA

University of Massachusetts Medical School

Lowell Arye, MS

Aging and Disability Policy and Leadership Consulting,

LLC

Amy Mullins, MD, CPE, FAAFP

American Academy of Family Physicians

Tricia Brooks, MBA

Georgetown University Center for Children and Families

Fred Oraene, MBA

Oklahoma Health Care Authority

Laura Chaise, MBA

Centene Corporation

Lisa Patton, PhD

IBM Watson Health

Lindsay Cogan, PhD, MS

New York State Department of Health

Jeff Schiff, MD, MBA

Minnesota Department of Human Services

James Crall, DDS, ScD, MS

UCLA School of Dentistry

Marissa Schlaifer, MS

OptumRx

Steve Groff

Delaware Department of Health and Social Services

Linette Scott, MD, MPH

California Department of Health Care Services

Kim Elliott, PhD, MA, CPHQ, CHCA

Health Services Advisory Group

Jami Snyder, MA

Arizona Health Care Cost Containment System

Tricia Elliott, MBA, CPHQ

The Joint Commission

Jennifer Tracey, MHA

Zero to Three

Shevaun Harris, MBA, MSW

Florida Agency for Health Care Administration

Sally Turbyville, DRPH, MS, MA

Children’s Hospital Association

Diana Jolles, PhD, CNM, FACNM

Frontier Nursing University

Bonnie Zima, MD, MPH

UCLA-Semel Institute for Neuroscience and Human

Behavior

Federal Liaisons (Non-voting)

Agency for Healthcare Research and Quality, HHS

Center for Clinical Standards & Quality, CMS, HHS

Centers for Disease Control and Prevention, HHS

Health Resources and Services Administration, HHS

Office of Infectious Disease and HIV/AIDS Policy (formerly National Vaccine Program Office), HHS

Office of the Assistant Secretary for Planning and Evaluation, HHS

Substance Abuse and Mental Health Services Administration, HHS

U.S. Department of Veterans Affairs

iii

ACKNOWLEDGEMENTS

This report was developed by Mathematica as part of the Technical Assistance and Analytic

Support for the Medicaid and CHIP Quality Measurement and Improvement Program, sponsored

by the Center for Medicaid and CHIP Services. The implementation of the 2020 Core Set

Review and production of the report was a team effort and we acknowledge the contributions of

the entire team.

Project director: Margo Rosenbach

Task leader: Bailey Orshan

Senior researchers: Rosemary Borck and Michaela Vine

Analysts: Allison Steiner, Chrissy Fiorentini, Ruth Hsu, and Steve Bruns

Task manager: Dayna Gallagher

Communications and administration: Christal Stone Valenzano, Brice Overcash, Brian

Willis, Fiona Shapiro, Derek Mitchell, Anthony Zampelli, Liah Caravalho, Autumn

Parker, Alyssa Smith, Shantal Alston James, Jess Coldren, and Colleen Fitts

Technical writers: Megan Thomas and Tanya Schwartz, Harbage Consulting

Mathematica would also like to acknowledge the contributions of the Workgroup members; each

member brought an invaluable perspective that informed the recommendations for the 2020

Child and Adult Core Sets. In particular, we thank the Workgroup co-chairs, Gretchen Hammer

and David Kelley, for their insightful facilitation and leadership.

In addition, we express our gratitude to the measure stewards contacted throughout the review

process. We appreciate the information they provided on the measures under consideration, and

for responding to questions from the Workgroup during the in-person meeting.

Finally, we thank the staff in the Division of Quality & Health Outcomes at the Center for

Medicaid and CHIP Services for their input and guidance.

CONTENTS

ACRONYMS ................................................................................................................................................. v

EXECUTIVE SUMMARY ............................................................................................................................. vii

INTRODUCTION ........................................................................................................................................... 1

OVERVIEW OF THE CHILD AND ADULT CORE SETS ............................................................................. 2

DESCRIPTION OF THE 2020 CORE SET ANNUAL REVIEW PROCESS ................................................. 5

STATE PERSPECTIVES ON CORE SET REPORTING ............................................................................. 9

WORKGROUP RECOMMENDATIONS FOR IMPROVING THE 2020 CORE SETS ................................ 10

NEXT STEPS .............................................................................................................................................. 21

APPENDIX A: CHILD AND ADULT CORE SET MEASURES .................................................................. A.1

APPENDIX B: SUMMARY OF 2020 CORE SET ANNUAL REVIEW WORKGROUP

DISCUSSION OF MEASURES NOT RECOMMENDED FOR REMOVAL OR ADDITION ..................... B.1

APPENDIX C: PUBLIC COMMENTS ON THE DRAFT REPORT ............................................................ C.1

ACRONYMS

ABA-AD Adult Body Mass Index

Assessment

APC-CH Use of Multiple Concurrent

Antipsychotics in Children

and Adolescents

ACA Affordable Care Act

ACE Angiotensin Converting

Enzyme

BMI Body Mass Index

BRFSS Behavioral Risk Factor

Surveillance System

CAHPS Consumer Assessment of

Healthcare Providers and

Systems

CAP-CH Child and Adolescents’

Access to Primary Care

Practitioners

CCP-AD Contraceptive Care –

Postpartum Women Ages

21–44

CCP-CH Contraceptive Care –

Postpartum Women Ages

15–20

CCW Contraceptive Care – All

Women

CDC Centers for Disease Control

and Prevention

CHIP Children’s Health Insurance

Program

CHIPRA Children’s Health Insurance

Program Reauthorization Act

CLABSI-CH Pediatric Central Line–

Associated Bloodstream

Infections

CMCS Center for Medicaid and

CHIP Services

CMS Centers for Medicare &

Medicaid Services

CV Curriculum Vitae

ECDS Electronic Clinical Data

Systems

EHR Electronic Health Record

FFY Federal Fiscal Year

FVA-AD Flu Vaccinations for Adults

Ages 18 to 64

HA1C-AD Comprehensive Diabetes

Care: Hemoglobin A1c

(HbA1c) Testing

HCBS Home- and Community-

Based Services

HEDIS Healthcare Effectiveness

Data and Information Set

HHS U.S. Department of Health

and Human Services

HIV Human Immunodeficiency

Virus

HPC-AD Comprehensive Diabetes

Care: Hemoglobin A1c

(HbA1c) Poor Control (> 9.0

percent)

ACRONYMS (continued)

HRSA Health Resources and

Services Administration

HSRI Human Services Research

Institute

HVL-AD HIV Viral Load Suppression

ICU Intensive Care Units

LTSS Long-Term Services and

Supports

MCO Managed Care Organization

MLTSS Managed Long-Term

Services and Supports

MPM-AD Annual Monitoring for

Patients on Persistent

Medications

MSC-AD Medical Assistance with

Smoking and Tobacco Use

Cessation

NCI

National Core Indicators

NCI-AD

National Core Indicators for

Aging and Disabilities

NCQA National Committee for

Quality Assurance

NQF National Quality Forum

OB/GYN Obstetrician/Gynecologist

OUD Opioid Use Disorder

PC01-AD PC-01: Elective Delivery

PC02-CH PC-02: Cesarean Birth

PCP Primary Care Practitioner

PDMP Prescription Drug Monitoring

Program

QMETRIC Quality Measurement,

Evaluation, Testing, Review,

and Implementation

Consortium

SUD Substance Use Disorder

TA/AS Technical Assistance and

Analytic Support Program

USPSTF U.S. Preventive Services

Task Force

WCC-CH Weight Assessment and

Counseling for Nutrition and

Physical Activity for

Children/Adolescents—Body

Mass Index Assessment for

Children/Adolescents

vii

EXECUTIVE SUMMARY

Medicaid and the Children’s Health Insurance Program (CHIP) provide health care coverage to

approximately 73 million people, including eligible children, pregnant women, low-income

adults, and individuals with disabilities.

The Centers for Medicare & Medicaid Services (CMS)

and its Center for Medicaid and CHIP Services (CMCS) use various tools to ensure that

Medicaid and CHIP beneficiaries receive health care coverage that promotes high quality care.

The Medicaid and CHIP Child and Adult Core Sets of health care quality measures (Core Sets)

are key components of this effort.

The Core Sets are used to assess the quality of care provided by states to Medicaid and CHIP

beneficiaries. The Core Sets are the mechanism for state reporting on a uniform set of measures

to facilitate state and national analyses, track performance over time, and use the results to drive

quality improvement in Medicaid and CHIP. Currently, state reporting on the Core Sets is

voluntary.

The Secretary of the U.S. Department of Health and Human Services is required to review and

update the Child and Adult Core Sets annually.

The annual Core Set review is designed to

identify gaps in existing quality measures and suggest updates to strengthen and improve the

Core Sets. The annual review includes input from numerous stakeholders, such as states, health

care providers, and quality experts.

CMCS contracted with Mathematica to convene the 2020 Child and Adult Core Set Annual

Review Stakeholder Workgroup (Workgroup). The Workgroup included 28 members, who

represented a diverse set of stakeholders based on affiliation, subject matter expertise, and

quality measurement and improvement experience (see inside front cover).

The Workgroup was charged with reviewing the 2019 Core Sets and recommending changes to

strengthen and improve the Core Sets for 2020. Workgroup members were asked to suggest

measures for removal from or addition to the Core Sets based on characteristics that support the

use of the Core Set measures for improving the quality of care for Medicaid and CHIP

beneficiaries. See Exhibit ES.1 for the characteristics Workgroup members considered during the

2020 Core Set review.

March 2019 Medicaid and CHIP Enrollment Data Highlights are available at

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-

highlights/index.html. Numbers reflect Medicaid and CHIP enrollment data as of March 2019, as reported by 50

states and the District of Columbia.

Annual updates to the Child Core Set are required under the Children’s Health Insurance Program Reauthorization

Act of 2009. Annual updates to the Adult Core Set are required under the Affordable Care Act.

viii

Exhibit ES.1. Characteristics Considered for Removal of Existing Measures and Addition

of New Measures

Characteristics Considered for Removal of Existing Measures

Actionability. Does the measure provide few useful or actionable results for state Medicaid and CHIP programs?

Clinical relevance. Does the measure no longer adhere to clinical evidence or guidelines?

Feasibility. Have states reported significant challenges to reporting the measure (such as barriers to accessing or

using data needed to report the measure)?

New or alternate measure. Is another measure being recommended to replace an existing Core Set measure?

Performance. Have states consistently reported a high level of performance on the measure, indicating little room

for improvement?

Characteristics Considered for Addition of New Measures

Actionability. Will the measure provide useful or actionable results for state Medicaid and CHIP programs?

Alignment. Is the measure used in other reporting programs?

Appropriateness for state-level reporting. Has the measure been validated and tested for state-level reporting? Is

it currently used by one or more states?

Feasibility. Will states be able to access the data needed to calculate the measure? Would technical assistance be

necessary or helpful to facilitate complete and accurate reporting of the measure by states?

Strategic priority. Does the measure fill a gap that has been identified in the Child or Adult Core Sets?

Workgroup members convened in person from May 7 to 9, 2019, to review 14 existing Core Set

measures suggested for removal from the 2020 Core Sets and 42 measures suggested for

addition. The 56 measures were presented, discussed, and voted on by domain.

To be

recommended for removal from or addition to the Core Sets, at least two-thirds of the eligible

Workgroup members were required to vote in favor of removal or addition. In summary, the

Workgroup recommended:

• Removal of 4 measures from the Child Core Set out of a total of 5 measures suggested for

removal

• Removal of 3 measures from the Adult Core Set out of a total of 9 measures suggested for

removal

• Addition of 5 measures to the Child and Adult Core Sets out of a total of 42 measures

suggested for addition

Exhibits ES.2 and ES.3 show the measures recommended for removal or addition, respectively.

The measures were organized by the following domains: Primary Care Access and Preventive Care, Maternal and

Perinatal Health, Care of Acute and Chronic Conditions, Behavioral Health Care, Dental and Oral Health

Services, Experience of Care: Patient-Reported Outcomes, Long-Term Services and Supports, and Other

Measures.

Exhibit ES.2. Summary of Workgroup Recommendations of Measures to Remove from

the 2020 Core Sets

Measure Name Measure Steward NQF # (if endorsed)

Recommended for Removal from the Child Core Set

Child and Adolescents’ Access to Primary Care

Practitioners (CAP-CH)

National Committee for

Quality Assurance (NCQA)

Not endorsed

Weight Assessment and Counseling for Nutrition

and Physical Activity for Children/Adolescents—

Body Mass Index Assessment for

Children/Adolescents (WCC-CH)

NCQA 0024

Pediatric Central Line–Associated Bloodstream

Infections (CLABSI-CH)

Centers for Disease Control

and Prevention

0139

Use of Multiple Concurrent Antipsychotics in

Children and Adolescents (APC-CH)

NCQA Not endorsed

Recommended for Removal from the Adult Core Set

Adult Body Mass Index Assessment (ABA-AD) NCQA Not endorsed

Comprehensive Diabetes Care: Hemoglobin A1c

(HbA1c) Testing (HA1C-AD)

NCQA 0057

Annual Monitoring for Patients on Persistent

Medications (MPM-AD)

NCQA

2371

The Workgroup recommended that the APC-CH measure be replaced by another measure: Metabolic Monitoring for

Children and Adolescents on Antipsychotics.

This measure is no longer endorsed.

NQF = National Quality Forum.

Exhibit ES.3. Summary of Workgroup Recommendations of Measures to Add to the 2020

Core Sets

Measure Name Measure Steward NQF # (if endorsed)

Appropriate Antibiotic Prophylaxis for Children

with Sickle Cell Anemia

QMETRIC—University of Michigan 3166

Metabolic Monitoring for Children and

Adolescents on Antipsychotics

NCQA 2800

Use of Pharmacotherapy for Opioid Use Disorder CMS 3400

National Core Indicators (NCI)

Human Services Research Institute

(HSRI) and National Association of

State Directors of Developmental

Disabilities Services

Not endorsed

National Core Indicators for Aging and Disabilities

(NCI-AD) Adult Consumer Survey

HSRI and National Association of

States United for Aging and

Disabilities

Not endorsed

The Workgroup recommended that this measure replace the Use of Multiple Concurrent Antipsychotics in Children

and Adolescents (APC-CH) measure in the Child Core Set.

NQF = National Quality Forum.

This report summarizes the Workgroup’s review process and recommendations. It also includes

the public comments submitted on the draft report. CMCS will use the Workgroup’s

recommendations, as well as public comments, to inform decisions about how and whether to

modify the 2020 Core Sets. CMCS will release the 2020 Core Sets through a CMCS

Informational Bulletin by December 31, 2019.

INTRODUCTION

Medicaid and the Children’s Health Insurance Program (CHIP) provided health care coverage to

approximately 73 million people in March 2019, including eligible children, pregnant women,

low-income adults, and individuals with disabilities (Exhibit 1).

The Centers for Medicare &

Medicaid Services (CMS) and its Center for Medicaid and CHIP Services (CMCS) use various

tools to ensure that Medicaid and CHIP beneficiaries receive health care coverage that promotes

high quality care. The Medicaid and CHIP Child and Adult Core Sets (Core Sets) of health care

quality measures are key components of this effort.

The goal of the Core Sets is to encourage state

reporting on a uniform set of measures to facilitate

state and national analyses, track performance over

time, and use the results to drive quality

improvement in Medicaid and CHIP. Currently,

state reporting on the Core Sets is voluntary.

The Secretary of the U.S. Department of Health

and Human Services (HHS) is required to review

and update the Child and Adult Core Sets

annually.

The annual Core Set review is designed

to identify gaps in existing quality measures and

suggest updates to strengthen and improve the

Core Sets. The Child Core Set has undergone

annual reviews since January 2013 and the Adult

Core Set since January 2014.

CMCS contracted with Mathematica to convene the 2020 Child and Adult Core Set Annual

Review Stakeholder Workgroup (Workgroup). The Workgroup included 28 members, who

represented a diverse set of stakeholders based on their affiliation, subject matter expertise, and

quality measurement and improvement experience (see inside front cover). The Workgroup was

charged with assessing the 2019 Core Sets and recommending measures that should be removed

as well as new measures that should be added, in order to strengthen and improve the Core Sets

for 2020. The Workgroup was asked to focus on measures that were feasible for state reporting

and that could be used to meaningfully drive quality improvement in Medicaid and CHIP.

This report provides an overview of the Child and Adult Core Sets, describes the 2020 Core Set

annual review process, shares state perspectives on Core Set reporting, summarizes the

Workgroup recommendations for improving the Core Sets, and presents the public comments

submitted about the draft report. CMCS will use the Workgroup’s recommendations, as well as

March 2019 Medicaid and CHIP Enrollment Data Highlights are available at

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-

highlights/index.html. Numbers reflect Medicaid and CHIP enrollment data as of March 2019, as reported by 50

states and the District of Columbia.

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) calls for annual updates to the

Child Core Set. The Affordable Care Act calls for annual updates to the Adult Core Set.

Source: 2017 CMS Actuarial Report (2016 data).

Aged

(65+)

Children

(nondisabled),

40%

Adults

(nondisabled),

37%

Individuals

with

disabilities,

15%

Exhibit 1. Distribution of Medicaid

Population, 2016

public comments, to inform decisions about how and whether to modify the 2020 Core Sets.

CMCS will release the 2020 Core Sets through a CMCS Informational Bulletin by December 31,

2019.

OVERVIEW OF THE CHILD AND ADULT CORE SETS

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) included

several provisions aimed at improving the quality of health care for children in Medicaid and

CHIP. CHIPRA required the HHS Secretary to identify and publish a core set of children’s

health care quality measures for voluntary use by state Medicaid and CHIP programs (referred to

as the Child Core Set). The initial Child Core Set, which was released in December 2009,

included 24 measures that covered both physical and mental health. The core set of health care

quality measures for adults covered by Medicaid (Adult Core Set) was established in 2010 under

the Patient Protection and Affordable Care Act (Affordable Care Act) in the same manner as the

Child Core Set. The initial Adult Core Set, which was released in January 2012, included 26

measures.

Appendix A contains tables showing the 2019 Child and Adult Core Set measures and the

history of measures included in the Child and Adult Core Sets from 2012 to 2019. Of the 26

measures in the 2019 Child Core Set, two-thirds were part of the initial Child Core Set.

Similarly, of the 33 measures in the 2019 Adult Core Set, two-thirds were part of the initial

Adult Core Set.

The 2019 Child Core Set

The 2019 Child Core Set includes 26 measures across six domains: (1) Primary Care Access and

Preventive Care, (2) Maternal and Perinatal Health, (3) Care of Acute and Chronic Conditions,

(4) Behavioral Health Care, (5) Dental and Oral Health Services, and (6) Experience of Care.

Nearly two-thirds of the 2019 Child Core Set measures fall into the Primary Care Access and

Preventive Care and Maternal and Perinatal Health domains (Exhibit 2). Seventy-three percent

are process measures and 85 percent can be calculated using administrative data only.

Exhibit 2. 2019 Child Core Set Measures, by Domain

For federal fiscal year (FFY) 2017 reporting, the most recent year for which data are publicly

available, all states voluntarily reported on at least one Child Core Set measure and 45 states

reported on at least half of the 26 measures in the 2017 Child Core Set. Twenty-one states

reported on more measures for FFY 2017 than for FFY 2016, and 47 states reported on both

Medicaid and CHIP populations. The median number of measures reported by states was 18.

Historically, the Child Core Set measures that are most frequently reported by states are related

to preventive dental services and primary care access and preventive care.

The 2019 Adult Core Set

The 2019 Adult Core Set includes 33 health care quality measures across five domains: (1)

Primary Care Access and Preventive Care, (2) Maternal and Perinatal Health, (3) Care of Acute

and Chronic Conditions, (4) Behavioral Health Care, and (5) Experience of Care. Two-thirds of

the measures are related to care of acute and chronic conditions and behavioral health care

(Exhibit 3). Seventy percent are process measures, and 88 percent can be calculated using

administrative data.

More information about the Child Core Set is available at https://www.medicaid.gov/medicaid/quality-of-

care/performance-measurement/child-core-set/index.html.

Primary Care Access

and Preventive Care

Maternal and Perinatal

Health

Care of Acute

and Chronic Conditions

Behavioral

Health Care

Dental and Oral Health

Services

Experience of Care

Core Set Domains

Exhibit 3. 2019 Adult Core Set Measures, by Domain

For FFY 2017 reporting, 45 states voluntarily reported on at least one Adult Core Set measure,

while 34 states reported on at least half of the 30 measures in the 2017 Adult Core Set. This

included 4 states that reported for the first time. Thirty-three states reported more measures for

FFY 2017 than for FFY 2016, with states reporting a median of 17 measures. Historically, the

Adult Core Set measures most frequently reported by states are spread across the domains.

Use of the Core Set for Quality Measurement and Improvement

CMCS and states use the Child and Adult Core Sets to monitor and improve the quality of care

provided to Medicaid and CHIP beneficiaries at the national and state levels and to measure

progress over time. CMCS publicly reports information on state performance on the Child and

Adult Core Sets annually through chart packs and other resources.

In addition, CMCS develops

initiatives to drive improvement in quality of care by using the Core Set measures—for example,

through its Maternal and Infant Health Initiative and Oral Health Initiative.

A subset of Core Set

More information about the Adult Core Set is available at https://www.medicaid.gov/medicaid/quality-of-

care/performance-measurement/adult-core-set/index.html.

Chart packs, measure-specific tables, fact sheets, and other information from annual Core Set reporting are

available at

https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-

set/index.html and https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-core-

set/index.html.

More information about Medicaid and CHIP quality improvement initiatives is available at

https://www.medicaid.gov/medicaid/quality-of-care/index.html.

measures is also included in the Medicaid and CHIP Scorecard to increase public transparency in

state health system performance.

To support states and their partners in collecting, reporting, and using the Core Set measures to

drive improvement in Medicaid and CHIP, CMCS established a Technical Assistance and

Analytic Support (TA/AS) Program. The TA/AS program provides one-on-one assistance to

address technical issues related to collecting the Core Set measures, offers group trainings and

collaborative learning opportunities, prepares issue briefs and analytic reports, and helps states to

design and implement quality improvement initiatives that use the Core Set measures.

DESCRIPTION OF THE 2020 CORE SET ANNUAL REVIEW

PROCESS

This section describes the 2020 Core Set annual review process, including the call for

nominations for Workgroup members, the Workgroup composition, and the Workgroup timeline

and meetings.

Call for Nominations

Mathematica issued a call for nominations on December 14, 2018; nomination forms and a

resume or CV were due on January 11, 2019. Mathematica distributed the call for nominations

electronically to a wide range of state Medicaid and CHIP officials, health care provider

associations, and quality measurement experts. Mathematica received 64 nominations.

Nominations were reviewed to address legislative requirements for the Core Set annual review,

to ensure geographic distribution, and to represent diverse areas of expertise.

Workgroup members were required to submit a Disclosure of Interest form to report any

interests, relationships, or circumstances over the past four years that could give rise to a

potential conflict of interest or the appearance of a conflict of interest related to the Child and

Adult Core Set measures or measures reviewed during the Workgroup process. Workgroup

members who were deemed to have an interest in a measure recommended for consideration

were required to recuse themselves from voting on that measure.

More information about the Medicaid and CHIP Scorecard is available at https://www.medicaid.gov/state-

overviews/scorecard/index.html.

More information about the CMCS TA/AS Program is available at https://www.medicaid.gov/medicaid/quality-

of-care/downloads/tafactsheet.pdf.

The statute requires representation from states, medical and dental professionals (including members of allied

health professions), providers caring for children and families who live in medically underserved urban and rural

communities, national organizations serving children and those with chronic conditions, consumers and

purchasers of health care, and experts in quality measures, as well as voluntary consensus standards-setting

organizations and other organizations involved in the advancement of evidence-based measures of health care.

Workgroup Composition

The Workgroup included 28 voting members from state Medicaid agencies, professional

associations, universities, hospitals, and other organizations from across the country (the

Workgroup members are listed on the inside front cover of this report).

As a whole, the

Workgroup represented expertise in primary care access and preventive care, acute and chronic

conditions, maternal and perinatal health, behavioral health and substance use, dental and oral

health, long-term services and supports, disability, experience of care, patient safety, and health

disparities. Although some Workgroup members were nominated by an organization, all

Workgroup members were asked to participate as subject matter experts and consider what

measures would be best for improving the quality of care in Medicaid and CHIP overall, and not

to advocate on behalf of an organization or a specific interest.

The Workgroup also included non-voting federal liaisons, who represented eight federal agencies

(see front cover). The inclusion of federal liaisons reflects CMCS’s commitment to promoting

quality measurement alignment and working in partnership with other agencies to collect, report,

and use the Core Set measures to drive improvement in Medicaid and CHIP.

Workgroup Timeline and Meetings

As shown in Exhibit 4, Mathematica held two webinars in February and April 2019 to orient the

Workgroup members and to prepare for the in-person Workgroup meeting, which was convened

in May 2019. The two webinars and the in-person meeting were open to the public and public

comment was invited at multiple points.

The draft report was made available for public comment from July 8, 2019 through August 5,

2019. Forty public comments were submitted. See Appendix C for more information on the

public comments received on the draft report. CMCS will release the 2020 Core Sets by

December 31, 2019, after taking into account Workgroup recommendations and public

comments.

Three additional members were selected but were unable to participate due to conflicts with their schedules.

Exhibit 4. 2020 Core Set Annual Review Stakeholder Workgroup Timeline

Orientation Webinar

During the orientation webinar on

February 14, 2019, Mathematica

stated the Workgroup charge,

introduced the Workgroup members

and disclosure of interest process,

described the timeline for the 2020

annual review, and provided

background on the Core Sets. In

addition, CMCS outlined its goals

for state reporting of the Core Sets:

1. Increase the number of states

reporting the measures

2. Increase the number of measures

reported by each state

3. Improve the quality of the data reported by states

4. Streamline the Core Set data collection and reporting processes

5. Use the data to drive improvements in health care quality and outcomes

Mathematica explained the process for Workgroup members to suggest measures for removal

from or addition to the Child and Adult Core Sets. The Workgroup was charged with focusing on

measures that met the following criteria:

• Actionable. Results can be used to improve care delivery and health outcomes.

FEB

Orientation webinar

Measure recommendations due

Webinar to prepare for

in-person meeting

In-person meeting

July 2019:

Draft report made available

for public comment

August 2019:

Final report released

By December 31, 2019:

2020 Core Sets released

MAR

APR

M AY

7-9

Workgroup Charge

The Child and Adult Core Set Stakeholder Workgroup for the 2020

Annual Review is charged with assessing the 2019 Core Sets and

recommending measures for removal or addition, in order to

strengthen and improve the Core Sets for 2020.

The Workgroup should focus on measures that are actionable,

aligned, and appropriate for state-level reporting to ensure that the

measures can meaningfully drive improvement in quality of care

and outcomes in Medicaid and CHIP.

• Aligned. Measures are aligned with those used in other programs to minimize burden on states,

health plans, and providers where possible.

• Appropriate. The technical specifications, data collection methods, and data sources are

validated for state use or can be easily adapted by states.

Following the orientation meeting, Workgroup members were invited to suggest measures for

removal from or addition to the 2020 Core Sets. Workgroup members used an online tool to

provide their suggestions for removal or addition, including the rationale and whether measures

suggested for addition were intended to substitute for a current Core Set measure. Workgroup

members suggested the following:

• Fourteen measures for removal, including 5 of the 26 measures in the 2019 Child Core Set

and 9 of the 33 measures in the 2019 Adult Core Set

• Forty-two measures for addition across the six current Core Set domains,

as well as two

new domains related to Long-Term Services and Supports (LTSS) and Other Measures

Webinar to Prepare for the In-Person Meeting

The second webinar took place on April 23, 2019. To help Workgroup members prepare for the

discussion at the in-person meeting, Mathematica shared a list of the 14 measures suggested for

removal and the 42 measures suggested for addition. Mathematica provided guidance on how to

prepare for the measures discussion at the in-person meeting, including the criteria that

Workgroup members should consider for recommending measures for removal from or addition

to the Core Sets and the resources available to facilitate their review. These resources included

detailed measure information sheets, a worksheet to facilitate the review and record notes, and a

Medicaid and CHIP beneficiary profile. Workgroup members were responsible for reviewing all

materials related to the measures and coming to the meeting prepared to ask questions and

discuss the merits of each measure.

In-Person Meeting

The in-person meeting took place in Washington, D.C., May 7-9, 2019. Workgroup members,

federal liaisons, measure stewards, and members of the public attended the meeting. Measure

stewards and members of the public were also able to participate virtually via webinar.

Before discussing individual measures for removal from or addition to the Core Sets, the state

representatives serving on the Workgroup shared their experiences with Core Set reporting. The

discussion helped other Workgroup members better understand how states use the Core Set

measures and their approach to collecting data and calculating measures.

The discussion of measures was organized into eight domains: the six current Core Set domains

plus LTSS and Other Measures. For each domain, Mathematica described the measures

The current domains are Primary Care Access and Preventive Care, Maternal and Perinatal Health, Care of Acute

and Chronic Conditions, Behavioral Health Care, Dental and Oral Health Services, and Experience of Care.

suggested for removal or addition, highlighted the key technical specifications, and summarized

the rationale Workgroup members provided for suggesting the measures for removal or addition.

The Workgroup co-chairs facilitated the discussion of the measures. They sought technical

questions from Workgroup members and asked the measure stewards to clarify measure

specifications when needed. The Workgroup members then discussed the measures suggested for

removal or addition in each domain. The co-chairs accepted motions to vote on the measures in

each domain, and there were opportunities for public comment on the measures suggested for

removal or addition. Public comments were accepted in person and via telephone.

Mathematica facilitated the voting on the measures. Workgroup members voted by using

iClicker devices, with voting results presented in real time. For each measure suggested for

removal, Workgroup members could select either “A = Yes, I recommend removing this

measure from the Core Set” or “B = No, I do not recommend removing this measure from the

Core Set.” For each measure recommended for addition, Workgroup members could select either

“A = Yes, I recommend adding this measure to the Core Set” or “B = No, I do not recommend

adding this measure to the Core Set.” Measures were recommended for removal or addition if

two-thirds of the eligible Workgroup members voted yes.

STATE PERSPECTIVES ON CORE SET REPORTING

Mathematica invited the Workgroup member from New York’s Medicaid agency to present on

the state’s experience with collecting, reporting, and using the Core Set measures, as well as on

its performance measurement priorities. In addition to programming claims and administrative

measures internally, the state leverages managed care reporting and collates information from

managed care organizations (MCOs) to report almost all of the Core Set measures. Key themes

from the presentation included the following:

• Effort and resources. New York devotes a high level of effort and resources to implement,

report, and maintain Core Set measures, even administrative measures. It can take several

years to get new Core Set measures up and running; even small tweaks to existing measures

require substantial staff effort.

• Types of measures. The state uses Healthcare Effectiveness Data and Information Set

(

HEDIS®) measures to benchmark internal measure calculations. Measures that are not part

of the HEDIS measure set are more difficult to benchmark because they are not audited like

HEDIS measures are. The representative also noted that provider-based measures (such as

those developed for hospitals) are more difficult for the state to collect and report.

• Measure alignment. Aligning measures with other programs is important. The state looks

for measures that support its existing initiatives, such as Medicaid Section 1115

demonstrations, as well as measures that can be monitored across all types of health

insurance (commercial and public). Alignment helps to drive measure prioritization by the

state, health plans, and provider organizations.

Workgroup members who disclosed an interest in a measure were recused from voting on that measure, for

example, if they were a measure developer, a measure steward, or paid to promote a measure in some way.

• Future priorities. Moving forward, New York is looking to end medical record review and

to more fully integrate electronic data, such as measure results from health information

exchanges, into its efforts. Use of electronic data will facilitate the state’s focus on

population health management and clinical care.

The Workgroup included representatives from eight other state Medicaid/CHIP agencies:

Arizona, California, Delaware, Florida, Massachusetts, Minnesota, Oklahoma, and Pennsylvania.

They also shared their on-the-ground experiences with reporting the current Core Set measures,

monitoring other measures as part of their state quality improvement programs, and using this

information to inform programmatic and policy decisions. In this context, the states noted the

importance of using data to understand subpopulations, including age groups, racial and ethnic

groups, and rural versus urban experiences. State representatives also focused on the feasibility

and burden of collecting and reporting measures, particularly when there are substantive changes

from year to year.

The state perspectives provided important context for the Workgroup discussion of individual

measures. Non-state Workgroup members frequently called on state representatives for insights

about their experiences with measures suggested for removal or their assessment of the

feasibility and usability of measures suggested for addition.

WORKGROUP RECOMMENDATIONS FOR IMPROVING THE

2020 CORE SETS

Criteria Considered by the Workgroup

The 2020 Core Set Annual Review Workgroup considered 56 measures, including 14 measures

suggested for removal and 42 measures suggested for addition. To guide the discussion and

voting, Workgroup members were asked to consider the “fit” of each individual measure for the

Core Set according to a series of characteristics introduced in the orientation webinar (see

Exhibit 5). Additional principles that guided the discussion and voting for measure removal or

addition included the following:

• There is no target number, or a minimum or maximum number, of measures that should be

included in the Core Sets.

• States should have the capacity and data available to report the measures; otherwise, data will

be limited and incomplete if measures cannot be reported by a majority of states.

• The importance of each individual measure should be considered without regard to the

relative importance of measures within and across domains.

• The merits of each individual measure should be assessed based on the current technical

specifications. Voting was based on the current measure; no suggestions for modifications

were allowed.

• The measures should be assessed without regard to whether they will be in the Child Core

Set or the Adult Core Set or what domain they will be in, because these decisions will be

made by CMCS.

Exhibit 5. Characteristics Considered for Removal of Existing Measures and Addition of

New Measures

Characteristics Considered for Removal of Existing Measures

Actionability. Does the measure provide few useful or actionable results for state Medicaid and CHIP programs?

Clinical relevance. Does the measure no longer adhere to clinical evidence or guidelines?

Feasibility. Have states reported significant challenges to reporting the measure (such as barriers to accessing or

using data needed to report the measure)?

New or alternate measure. Is another measure being recommended to replace an existing Core Set measure?

Performance. Have states consistently reported a high level of performance on the measure, indicating little room

for improvement?

Characteristics Considered for Addition of New Measures

Actionability. Will the measure provide useful or actionable results for state Medicaid and CHIP programs?

Alignment. Is the measure used in other reporting programs?

Appropriateness for state-level reporting. Has the measure been validated and tested for state-level reporting? Is

it currently used by one or more states?

Feasibility. Will states be able to access the data needed to calculate the measure? Would technical assistance be

necessary or helpful to facilitate complete and accurate reporting of the measure by states?

Strategic priority. Does the measure fill a gap that has been identified in the Child or Adult Core Sets?

Summary of Workgroup Recommendations

The Workgroup recommended the removal of four measures from the Child Core Set, the

removal of three measures from the Adult Core Set (Exhibit 6), and the addition of five measures

to the Core Sets (Exhibit 7). This section summarizes the discussion and rationale for the

measures recommended for removal from or addition to the 2020 Core Sets. Additional

information on the measures not recommended for removal from or addition to the Core Sets is

included in Appendix B.

Exhibit 6. Summary of Workgroup Recommendations of Measures to Remove from the

2020 Core Sets

Measure Name Measure Steward NQF # (if endorsed)

Recommended for Removal from the Child Core Set

Child and Adolescents’ Access to Primary Care

Practitioners (CAP-CH)

National Committee for

Quality Assurance (NCQA)

Not endorsed

Weight Assessment and Counseling for Nutrition

and Physical Activity for Children/Adolescents—

Body Mass Index Assessment for

Children/Adolescents (WCC-CH)

NCQA 0024

Pediatric Central Line–Associated Bloodstream

Infections (CLABSI-CH)

Centers for Disease Control

and Prevention

0139

Use of Multiple Concurrent Antipsychotics in

Children and Adolescents (APC-CH)

NCQA Not endorsed

Measure Name Measure Steward NQF # (if endorsed)

Recommended for Removal from the Adult Core Set

Adult Body Mass Index Assessment (ABA-AD) NCQA Not endorsed

Comprehensive Diabetes Care: Hemoglobin A1c

(HbA1c) Testing (HA1C-AD)

NCQA 0057

Annual Monitoring for Patients on Persistent

Medications (MPM-AD)

NCQA

2371

The Workgroup recommended that the APC-CH measure be replaced by another measure: Metabolic Monitoring for

Children and Adolescents on Antipsychotics.

This measure is no longer endorsed.

NQF = National Quality Forum.

Exhibit 7. Summary of Workgroup Recommendations of Measures to Add to the 2020

Core Sets

Measure Name Measure Steward NQF # (if endorsed)

Appropriate Antibiotic Prophylaxis for Children

with Sickle Cell Anemia

QMETRIC— University of

Michigan

3166

Metabolic Monitoring for Children and

Adolescents on Antipsychotics

NCQA 2800

Use of Pharmacotherapy for Opioid Use

Disorder

CMS 3400

National Core Indicators (NCI)

Human Services Research

Institute (HSRI) and National

Association of State Directors of

Developmental Disabilities

Services

Not endorsed

National Core Indicators for Aging and

Disabilities (NCI-AD) Adult Consumer Survey

HSRI and National Association of

States United for Aging and

Disabilities

Not endorsed

The Workgroup recommended that this measure replace the Use of Multiple Concurrent Antipsychotics in Children

and Adolescents (APC-CH) measure in the Child Core Set.

NQF = National Quality Forum.

Measures Recommended for Removal from the Child Core Set

Child and Adolescents’ Access to Primary Care Practitioners (CAP-CH)

The CAP-CH measure assesses the percentage of children and adolescents who had a visit with a

primary care practitioner (PCP). Four rates are reported: children ages 12 to 24 months and 25

months to age 6 who had a visit with a PCP during the measurement year; and children ages 7 to

11 and adolescents ages 12 to 19 who had a visit with a PCP during the measurement year or the

year prior to the measurement year. Forty-eight states reported this measure for FFY 2017.

The Workgroup member who suggested the measure for removal indicated that the measure does

not provide useful or actionable results for state Medicaid and CHIP agencies; the measure uses

a very broad definition of primary care visits, which makes it more a utilization measure than a

quality measure. The member stated that true access to primary care involves a well-care visit,

which is already covered by three Child Core Set well-care measures.

Another Workgroup member noted that relatively high performance on the access to care

measure does not necessarily correlate with children actually receiving the recommended well-

child care. It was suggested that the three well-child visit measures in the 2019 Child Core Set

could serve as substitutes for this measure. Finally, the measure steward, the National Committee

for Quality Assurance (NCQA), proposed retiring the measure in 2018, which raised concerns

for the Workgroup about whether the measure would be maintained and updated if NCQA

retired the measure and it remained in the Core Set.

Weight Assessment and Counseling for Nutrition and Physical Activity for

Children/Adolescents—Body Mass Index Assessment for

Children/Adolescents (WCC-CH)

The WCC-CH measure assesses the percentage of children ages 3 to 17 who had a visit with a

PCP or OB/GYN practitioner and whose body mass index (BMI) percentile was documented in

the medical record. This measure documents evidence of BMI measurement only, and does not

include a counseling component. Thirty-seven states reported this measure for FFY 2017.

The Workgroup members who suggested the measure for removal described it as a

documentation measure that does not provide useful or actionable results for state Medicaid and

CHIP agencies. They further asserted that this measure does not reflect evidence-based practices

for interventions for children with or at risk of obesity. One Workgroup member also noted that

the data collection burden for this measure does not support its use, particularly because the

measure does not support an evidence-based practice.

Workgroup members also noted that, although state focus on childhood obesity is critical, the

clinical evidence to support the measure is lacking. One Workgroup member asserted that more

integrated and effective models to address obesity than screening alone, such as referrals to care,

should be prioritized in the Core Set. It was also noted that this measure is reported under the

Promoting Interoperability Program (formerly the Electronic Health Record [EHR] Incentive

Program), so removal of the measure from the Child Core Set would not disincentivize

physicians from conducting a BMI assessment.

One federal liaison voiced support for the child and adult BMI screening measures, noting there

is evidence to support BMI screening in the primary care setting and that BMI screening is part

of the U.S. Preventive Services Task Force (USPSTF) recommendations for both children and

adults. The commenter also cautioned about sending a signal about the low priority of this topic

if the WCC-CH measure is removed from the Child Core Set without a replacement.

Pediatric Central Line–Associated Bloodstream Infections (CLABSI-CH)

The CLABSI-CH measure assesses the number of CLABSIs in neonatal intensive care units

(ICUs) reported by acute care hospitals. The standardized infection ratios reported for each state

compare the observed number of infections reported during the measurement period to the

predicted number of infections for that period. Data for the measure are reported by hospitals to

Although the CAP measure was proposed for retirement from HEDIS 2018, the measure remains in HEDIS 2020

as a result of feedback through stakeholder discussions and public comments.

Due to limitations of claims data to calculate this measure, the hybrid data collection method, which uses a

combination of administrative and medical records, is typically required to produce accurate results.

the Centers for Disease Control and Prevention (CDC) in the National Health Care Safety

Network. Data reported to CDC are for all payers and not limited to Medicaid and CHIP.

Although the Core Set specifications include both neonatal and pediatric ICUs, CDC only reports

data for neonatal ICUs, so the Core Set data available for this measure include only neonatal

ICUs. CMCS obtains data for this measure directly from CDC each year.

The Workgroup member who suggested the CLABSI-CH measure for removal noted that the

measure does not provide useful or actionable results for state Medicaid and CHIP agencies.

Workgroup members discussed the value of measuring and tracking CLABSIs. One noted that

states have successfully worked across state agencies and with other states to use the data to

achieve reductions in pediatric CLABSIs. At the same time, Workgroup members questioned

whether the statewide data reported for the CLABSI measure were more actionable for state

departments of public health, which typically have regulatory authority over hospitals and

hospital-focused metrics, than for Medicaid agencies. Furthermore, this measure is not limited to

populations covered by Medicaid and CHIP. A Workgroup member from one state explained

that because the Medicaid agency does not have the raw data to focus on Medicaid beneficiaries

or review rates at the county or managed care plan level, it is challenging to use the measure to

drive quality improvement in the Medicaid or CHIP program. Workgroup members also

discussed how removing the measure from the Core Set would not necessarily undermine or

terminate the existing focus in states and departments of public health to continue to use

CLABSI data to improve hospital safety and quality and provide accountability at the state level.

Use of Multiple Concurrent Antipsychotics in Children and Adolescents

(APC-CH)

The APC-CH measure assesses the number of beneficiaries on two or more concurrent

antipsychotic medications for at least 90 consecutive days during the measurement year. Thirty-

seven states reported this measure for FFY 2017. The measure is currently included on the

Medicaid and CHIP Scorecard. This measure will be retired from HEDIS in 2020 and will no

longer be updated and maintained by the measure steward (NCQA).

The Workgroup member who suggested the measure for removal noted that state efforts have led

to high performance on this measure with little room for improvement. In 2017, the median rate

for this measure was 2.7 percent (lower rates are better). Moreover, the number of children in the

denominator has decreased over time, suggesting that the overall number of children on two or

more concurrent antipsychotic medications has decreased. Another measure of appropriate

antipsychotic treatment with a larger denominator, Metabolic Monitoring for Children and

Adolescents on Antipsychotics, was recommended as a replacement for this measure.

Workgroup members suggested that high performance on this measure may indicate that states

have achieved the appropriate level of utilization. Moreover, it was noted that there may be a

clinical justification for a small number of children to be prescribed these medications.

Workgroup members representing states commented that they would continue to track similar

measures, particularly for children in foster care, if this measure is removed from the Core Set.

Measures Recommended for Removal from the Adult Core Set

Adult Body Mass Index Assessment (ABA-AD)

The ABA-AD measure assesses the percentage of beneficiaries ages 18 to 74 who had an

outpatient visit and whose BMI was documented in the medical record. Thirty-two states

reported this measure for FFY 2017.

The rationale Workgroup members provided for suggesting removal of this measure was similar

to the rationale for removing the WCC-CH measure from the Child Core Set. As a measure of

documentation, rather than outcomes or evidence-based practices for combatting obesity, ABA-

AD does not assess whether a high BMI value resulted in follow-up services.

During the discussion, Workgroup members noted that this measure was routinely reported

under the Promoting Interoperability Program (formerly the EHR Incentive Program), as BMI is

often collected in EHRs. The Preventive Care and Screening: Body Mass Index Screening and

Follow-Up Plan measure was discussed as a replacement for this measure, which would move

the measure in the direction of treatment rather than documentation. However, this measure was

not ultimately recommended for addition because of concerns about states’ access to data to

calculate the measure, among other factors. One Workgroup member also noted that combatting

obesity may require a broader societal response than other health conditions, which makes it

more challenging for the health care system to address.

As mentioned earlier, one federal liaison voiced support for the child and adult BMI screening

measures, noting that there is evidence to support BMI screening in the primary care setting and

that BMI screening is part of American Academy of Pediatrics and USPSTF recommendations

for both children and adults. The commenter also cautioned about sending a signal about the low

priority of this topic if the ABA-AD measure were removed from the Adult Core Set without a

replacement.

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing (HA1C-AD)

The HA1C-AD measure assesses the percentage of beneficiaries ages 18 to 75 with diabetes

(types 1 and 2) who had a hemoglobin A1c (HbA1c) test. Thirty-eight states reported this

measure for FFY 2017.

The Workgroup members who suggested it for removal commented that the high performance on

the measure indicated that there was little room for improvement. They also noted that a measure

currently on the Core Set—Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor

Control (> 9.0 percent) (HPC-AD)—is an outcome measure that also assesses whether testing is

being conducted. Removing the HA1C-AD measure would reduce state reporting burden without

losing the value of measuring diabetes control.

Two Workgroup members representing states noted that they no longer use this measure because

the HPC-AD measure includes a testing component; further, they want to hold plans accountable

for improved outcomes, rather than just testing. A Workgroup member also noted that the

HA1C-AD and HPC-AD measures are on the Core Set concurrently because not all states were

equipped to report on the HPC-AD measure when it was added. One member expressed concern

about removing this measure without knowing the screening rates in the 12 states that are not

reporting the measure.

Annual Monitoring for Patients on Persistent Medications (MPM-AD)

The MPM-AD measure assesses the percentage of beneficiaries age 18 and older who received at

least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during

the measurement year and at least one therapeutic monitoring event for the therapeutic agent in

the measurement year. The therapeutics agents include angiotensin converting enzyme (ACE)

inhibitors or angiotensin receptor blockers (ARB) and diuretics. Thirty-six states reported on this

measure for FFY 2017. This measure will be retired from HEDIS in 2020 and will no longer be

updated and maintained by the measure steward (NCQA).

One Workgroup member recommended this measure for removal because states report high

performance rates on the measure, which indicates that there is little room for improvement. It

was also noted that the measure lost NQF endorsement in 2018.

During the Workgroup discussion, a Workgroup member representing a state noted that the high

performance rates have led them to remove this measure from their pay-for-performance

program. Another member described MPM-AD as a process measure that does not get to

outcomes.

Measures Recommended for Addition to the 2020 Core Sets

Appropriate Antibiotic Prophylaxis for Children with Sickle Cell Anemia

This measure assesses the percentage of children ages 3 months to 5 years who were identified as

having sickle cell anemia and who received appropriate antibiotic prophylaxis during the

measurement year.

One Workgroup member suggested this measure for addition because individuals with sickle cell

anemia, particularly infants and young children, are susceptible to life-threatening infections.

Antibiotic prophylaxis is a relatively easy and inexpensive care pathway that is underutilized.

During the discussion, the Workgroup compared this measure to another sickle cell measure

suggested for addition, Transcranial Doppler Ultrasonography Screening for Children with

Sickle Cell Anemia.

During the discussion, the Workgroup generally favored the antibiotic prophylaxis measure from

a clinical perspective, with members characterizing it as a measure of continuity of chronic

disease care that should be universally performed in all situations—compared to a transcranial

Doppler ultrasonography, which is a one-time screening that has to be linked to further

downstream processes. Workgroup members noted the disparities in the use of antibiotic

prophylaxis treatment and the opportunity for improvement. One Workgroup member also noted

that this was an administrative claims-based measure, so it was feasible for states to collect and

report. Finally, one Workgroup member noted that, because sickle cell anemia is a genetic

disease, the prevalence varies by state; therefore, this measure may or may not be a high priority

for states based on the size of their affected population.

Metabolic Monitoring for Children and Adolescents on Antipsychotics

This measure assesses the percentage of children and adolescents age 1 to 17 who had at least

two antipsychotic medication dispensing events of the same or different medication and had

monitoring for the development of abnormal cholesterol and blood sugar levels, which are

known side effects of these medications. An updated version of the measure is currently under

consideration that would combine the 1- to 5-year-old and 6- to 11-year-old age groups and add

separate rates for blood glucose and cholesterol. This measure was recommended to replace the

Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC-CH) measure,

which was recommended for removal from the Child Core Set.

The Workgroup member who suggested this measure noted that it would help states monitor

children on multiple concurrent antipsychotics (children previously identified by the APC-CH

measure) by identifying any gaps in their metabolic follow-up. The Workgroup member noted

that the Medicaid HEDIS national average for appropriate monitoring for children on these

medications was 34 percent in 2017, which suggests a gap in the quality of care provided to these

children.

One Workgroup member commented that this is one of the few measures that monitors

medication safety for children on psychotropic medications. In addition, the denominator for this

measure is larger than the denominator for APC-CH, which this measure was recommended to

replace.

Use of Pharmacotherapy for Opioid Use Disorder

This measure assesses the percentage of Medicaid beneficiaries ages 18 to 64 with an opioid use

disorder (OUD) who filled a prescription for, or were administered or ordered, a Food and Drug

Administration–approved medication for the disorder during the measurement year.

The Workgroup member who suggested this measure noted that it would fill a current gap in the

Core Sets by tracking the appropriate treatment of OUDs, which is a critical step in curbing the

national OUD epidemic.

One Workgroup member noted that while this measure does not assess treatment adherence, it

does provide information about the number of people initiating medication assistance treatment,

which is a good first step. Other members expressed that continuity of treatment is equally

important.

National Core Indicators (NCI) and National Core Indicators for Aging and

Disabilities (NCI-AD)

The NCI and NCI-AD assess the experience and outcomes of individuals with intellectual and

developmental disabilities and their families, and seniors and adults with physical disabilities,

respectively. Both are voluntary efforts undertaken by state developmental disabilities agencies

(NCI) and state Medicaid aging and disability agencies (NCI-AD).

• NCI surveys assess the experience of people who receive services from state developmental

disabilities agencies. It includes an in-person survey, family surveys for parents and

guardians of adults and children who receive supports, and a staff stability survey. Indicators

address key areas of concern in five domains: (1) individual outcomes; (2) health, welfare,

and rights; (3) system performance; (4) staff stability; and (5) family outcomes. Forty-six

states participate in the NCI program; 37 states collected data through NCI’s in-person

survey in 2018-2019.

• NCI-AD core indicators are standard measures used across states to assess the outcomes of

services provided to seniors and adults with physical disabilities. Indicators address 19 key

areas of concern including (1) service coordination, (2) rights and respect, (3) community

participation, (4) choice and decision-making, (5) health care, (6) safety, (7) relationships, (8)

satisfaction, (9) care coordination, (10) access to community, (11) access to needed

equipment, (12) wellness, (13) medications, (14) self-direction, (15) work, (16) everyday

living, (17) affordability, (18) control, and (19) person-centered planning. Seventeen states

collected NCI-AD data in 2018-2019.

The Workgroup member who suggested the measures noted that they would fill a gap in the Core

Sets related to LTSS for people with intellectual and developmental disabilities or for those who

use home- and community-based services (HCBS). Workgroup members acknowledged that

LTSS accounts for a substantial portion of Medicaid expenditures and that a large portion of

Medicaid beneficiaries use these services.

Workgroup members discussed the fact that many states are currently using the NCI and NCI-

AD measures; whereas other proposed measures, such as the Consumer Assessment of

Healthcare Providers and Systems Home and Community Based Services (HCBS CAHPS),

survey are newer. Workgroup members with experience using the NCI and NCI-AD measures in

their states articulated several advantages:

• Both sets of indicators have provided actionable results to states on beneficiary outcomes in

terms of function and well-being. In addition to calculating state-level rates, some states

oversample to assess performance for subpopulations within the state, including performance

by managed care plan, provider, region, and county. One Workgroup member reported that

her state was able to use the individual-level survey results to implement quality

improvement activities that made a difference in people’s lives.

• Both sets of indicators are aligned with measures used for other reporting programs and can

be used for both managed care and fee-for-service populations.

• Both sets of indicators have been tested and are believed to be valid and reliable, with strong

inter-rater reliability. In addition, technical assistance is available to states for implementing

the surveys. Multiple years of comparative data are available so that states can benchmark

their performance and progress.

Workgroup members acknowledged that adding new survey-based measures to the Core Set

would require states to either add requirements for these surveys to managed care contracts or to

field them directly. At the same time, measures from other data sources that assess the

experience of beneficiaries and their functional status and well-being are not currently available.

The NCI and NCI-AD surveys are accessible in multiple languages to people with disabilities

who are nonverbal, blind, deaf, or have other disabilities; both are also available in Spanish.

Cross-Cutting Themes in Measure Discussions

Several cross-cutting themes emerged from the Workgroup discussions about measures

suggested for removal or addition:

• Feasibility. One of the strongest considerations that Workgroup members expressed was the

feasibility for states to collect and report the measures. Throughout the meeting, Workgroup

members asked colleagues representing state Medicaid programs for their opinions on the

feasibility of measures. It was noted that feasibility varies by state, particularly related to

whether states have managed care delivery systems and are able to leverage MCOs to support

Core Set reporting. The Workgroup noted that measures that use already available

administrative data or measures used for other purposes (such as in pay for performance

programs) are more feasible. As part of this discussion, some Workgroup members

representing states expressed concern about survey-based measures due to the high level of

effort and resources required to administer surveys.

• Appropriateness. Workgroup members highlighted that the most appropriate measures for

the Core Sets are those in which state-to-state comparisons would be helpful in monitoring

the quality of care in Medicaid and CHIP. Given variations in state Medicaid programs and

delivery systems, the results of some measures may not be meaningful when compared

across states. Other measures may be more appropriate to monitor at the plan or provider

levels. Workgroup members repeatedly stressed that nothing about the value of the measure

or the importance of the topic area should be inferred from the decision not to recommend it

for addition to the Core Sets.

• Readiness. Workgroup members discussed whether measures were ready for implementation

in the Core Sets and for Medicaid and CHIP. For example, there were concerns about using

first-year HEDIS measures and measures that had not been tested for use in state Medicaid

programs. Workgroup members commented that the Core Sets are not the place to put new

measures or measures untested at the state level.

• Actionability. Workgroup members noted the importance of ensuring that Core Set measures

are actionable, that is, that CMCS and states can use the data to inform program and policy

decisions and to improve the quality of care for Medicaid and CHIP beneficiaries. There was

ample discussion in support of working toward moving from process to outcome measures as

they become feasible and ready. Outcome measures are necessary to more fully understand

the quality of care provided to Medicaid and CHIP beneficiaries.

Discussion of Core Set Measure Gaps

The Workgroup discussed improving the Core Sets by taking a holistic approach to measuring

the quality of care provided to diverse populations and subpopulations enrolled in Medicaid and

CHIP. Workgroup members frequently cited the need to address issues related to social

determinants of health as a gap area in the Core Sets, either as measures themselves or to risk

adjust measures for valid comparison. Workgroup members noted that the measures in the Core

Set are heavily focused on medical care, whereas Medicaid programs provide wraparound

services that are not being captured by the current Core Set measures. Workgroup members

acknowledged feasibility challenges for measuring and addressing the social determinants of

health; however, they suggested that CMCS, measure stewards, and states work together to

promote inclusion of such measures in quality measurement efforts.

Workgroup members expressed their preference for having a gap in the Core Set rather than

recommending measures that did not meet the specified criteria, and especially to avoid

increasing burden on states. In addition, because measures continue to be tested, the Workgroup

noted that many of the measures that were not recommended should be reconsidered in the

future. The Workgroup suggested potential gap areas that could be considered for future Core

Set measures (Exhibit 8).

Exhibit 8. Potential Gap Areas for Future Core Set Measures

Populations Health Areas

Health Care Delivery

Other Measure

Attributes

• Adolescent and young

adults

• Children in foster care

• Maternal health

• Men’s health

• Individuals with multiple

chronic conditions

• Elderly individuals,

including those who are

Medicare-Medicaid dual

eligibles

• Individuals of all ages

with disabilities,

including access to

services and supports to

assist them with living

and participating in the

community safely

• Immunizations

(prenatal, adult)

• Obesity

• Adverse childhood

experiences

• Child social and

emotional development

• LTSS (including

rebalancing)

• Oral health beyond

prevention

• Access to oral health

care for individuals with

special needs

• Behavioral health

integration in acute

medical settings

• Depression

• Suicide

• Trauma-informed care

• Rare diseases

• Follow-up on referrals

• Care transitions (e.g.,

from hospital or nursing

home to the community)

• Appropriateness of

care—underutilization

and overutilization

• Workforce and caregiver

supports

• Provider accountability

• Network adequacy

• Stratification by race

and ethnicity

• Measures addressing

social determinants of

health

• Measures with life

course potential

• Measures that cut

across Medicaid and

Medicare

Additional Workgroup Suggestions for Improving the Core Sets

In addition to making recommendations for specific measures, the Workgroup members

discussed improvements for the Core Sets and quality measurement more broadly.

Considering the Various Uses of Quality Measures in Medicaid and CHIP

Workgroup members representing state Medicaid and CHIP agencies noted that they use quality

measures for various purposes and indicated that not all measures are appropriate for the Core

Sets. Several state representatives, for example, expressed enthusiasm for taking some of the

measures back to their state, including some that the Workgroup did not recommend for addition

to the Core Set. State representatives noted that there are a lot of good measures that may not be

appropriate for the Core Set but that would be useful to states as part of their own quality

monitoring activities, such as evaluation of Medicaid Section 1115 and other waivers, managed

care oversight, and value-based purchasing.

Integrating Health Information Technology

The Workgroup stressed the importance of integrating health information technology, including

EHRs and electronic data extraction, into quality reporting efforts. Like New York, other state

representatives noted they were on a path toward integrating electronic data into reporting

efforts. One Workgroup member noted that states have made substantial investments in

hospitals, health systems, and providers to report electronic measures but that many states are not

yet yielding the value of these investments because reporting is difficult. To get to true

meaningful use, several members recommended that federal agencies work together to direct

resources and attention to electronic initiatives to assist states in collecting electronic quality

measures.

Creating Shared Learning and Technical Assistance Opportunities

Several Workgroup members suggested that federal agencies, including CMCS, provide shared

learning opportunities for states in the following areas:

• Racial and ethnic stratification. Several Workgroup members suggested providing

technical assistance to help states better understand the racial and ethnic makeup of their

Medicaid and CHIP population and the experiences of different racial and ethnic groups in

the health care system. This includes assistance in standardizing the collection of data on race

and ethnicity makeup.

• Data linkages. Workgroup members noted the need to link data for families in Medicaid to

better understand their needs and service patterns. For example, one Workgroup member

noted data challenges with pairing mothers and their babies in order to monitor the link

between perinatal services and child health outcomes.

• Medicaid and immunization registry coordination. A Workgroup member recommended

that CMCS consider an affinity group or grant opportunity to help drive state coordination

between Medicaid and public health registries, particularly immunization registries.

• State quality staff connections. A Workgroup member recommended convening an affinity

group for state quality staff to help them understand their work across states. They noted that

connecting with other staff working on the same issues could help with staff morale and

retention.

NEXT STEPS

The 2020 Core Set Annual Review Workgroup considered 14 measures for removal from the

Core Sets and 42 measures for addition. Workgroup members recommended the removal of 7

measures and the addition of 5 measures to the 2020 Core Sets. For the first time, the Workgroup

recommended adding 2 measures on LTSS and one measure on the treatment of opioid abuse.

The Workgroup considered such characteristics as the feasibility, appropriateness, readiness, and

actionability of measures for the Core Sets. Workgroup members discussed whether measures

were ready for implementation in the Core Sets and for Medicaid and CHIP. Workgroup

members commented that the Core Sets are not the place to put new or untested measures.

Workgroup members also repeatedly stressed that nothing about the value of the measure or the

importance of the topic area should be inferred from the decision not to recommend a measure

for addition to the Core Sets.

The draft report was available for public comment from July 8, 2019 through August 5, 2019.

Forty public comments were submitted. CMCS will use the Workgroup recommendations and

the public comments to inform decisions about how and whether to modify the Core Sets for

2020. CMCS will release the 2020 Core Sets through a CMCS Informational Bulletin by

December 31, 2019.

Appendix A

Child and Adult Core Set Measures

This page has been left blank for double-sided copying.

A.3

Exhibit A.1. 2019 Core Set of Children’s Health Care Quality Measures for Medicaid and

CHIP (Child Core Set)

NQF #

Measure

steward Measure name Data collection method

Primary Care Access and Preventive Care

0024 NCQA

Weight Assessment and Counseling for Nutrition and

Physical Activity for Children/Adolescents – Body Mass

Index Assessment for Children/Adolescents (WCC-CH)

Administrative, hybrid, or

EHR

0033 NCQA Chlamydia Screening in Women Ages 16–20 (CHL-CH) Administrative or EHR

0038 NCQA Childhood Immunization Status (CIS-CH)

Administrative, hybrid, or

EHR

0418/0418e CMS

Screening for Depression and Follow-Up Plan: Ages

12–17 (CDF-CH)

Administrative or EHR

1392 NCQA

Well-Child Visits in the First 15 Months of Life (W15-

CH)

Administrative or hybrid

1407 NCQA Immunizations for Adolescents (IMA-CH) Administrative or hybrid

1448* OHSU

Developmental Screening in the First Three Years of

Life (DEV-CH)

Administrative or hybrid

1516 NCQA

Well-Child Visits in the Third, Fourth, Fifth, and Sixth

Years of Life (W34-CH)

Administrative or hybrid

Not endorsed NCQA Adolescent Well-Care Visits (AWC-CH) Administrative or hybrid

Not endorsed NCQA

Children and Adolescents’ Access to Primary Care

Practitioners (CAP-CH)

Administrative

Maternal and Perinatal Health

0139 CDC

Pediatric Central Line-Associated Bloodstream

Infections (CLABSI-CH)

Medical records (CDC’s

NHSN)

0471 TJC PC-02: Cesarean Birth (PC02-CH) Hybrid

1360 CDC

Audiological Diagnosis No Later Than 3 Months of Age

(AUD-CH)

EHR

1382 CDC

Live Births Weighing Less Than 2,500 Grams (LBW-

CH)

State vital records

1517* NCQA

Prenatal and Postpartum Care: Timeliness of Prenatal

Care (PPC-CH)

Administrative or hybrid

2902 OPA

Contraceptive Care – Postpartum Women Ages 15–20

(CCP-CH)

Administrative

2903/2904 OPA

Contraceptive Care – All Women Ages 15–20 (CCW-

CH)

Administrative

Care of Acute and Chronic Conditions

1800 NCQA Asthma Medication Ratio: Ages 5–18 (AMR-CH) Administrative

Not endorsed NCQA

Ambulatory Care: Emergency Department (ED) Visits

(AMB-CH)

Administrative

Behavioral Health Care

0108 NCQA

Follow-Up Care for Children Prescribed Attention-

Deficit/Hyperactivity Disorder (ADHD) Medication

(ADD-CH)

Administrative or EHR

0576 NCQA

Follow-Up After Hospitalization for Mental Illness: Ages

6–17 (FUH-CH)

Administrative

Exhibit A.1. (continued)

A.4

NQF #

Measure

steward Measure name Data collection method

2801 NCQA

Use of First-Line Psychosocial Care for Children and

Adolescents on Antipsychotics (APP-CH)

Administrative

Not endorsed NCQA

Use of Multiple Concurrent Antipsychotics in Children

and Adolescents (APC-CH)

Administrative

Dental and Oral Health Services

2508*

DQA

(ADA)

Dental Sealants for 6–9 Year-Old Children at Elevated

Caries Risk (SEAL-CH)

Administrative

Not endorsed CMS

Percentage of Eligibles Who Received Preventive

Dental Services (PDENT-CH)

Administrative (Form

CMS-416)

Experience of Care

Not endorsed NCQA

Consumer Assessment of Healthcare Providers and

Systems (CAHPS®) Health Plan Survey 5.0H – Child

Version Including Medicaid and Children with Chronic

Conditions Supplemental Items (CPC-CH)

Survey

More information on 2019 Updates to the Child and Adult Core Health Care Quality Measurement Sets is available at

https://www.medicaid.gov/federal-policy-guidance/downloads/cib112018.pdf.

*This measure is no longer endorsed by NQF.

CDC = Centers for Disease Control and Prevention; CHIP = Children's Health Insurance Program; CMS = Centers for

Medicare & Medicaid Services; DQA (ADA) = Dental Quality Alliance (American Dental Association); EHR =

Electronic Health Record; NCQA = National Committee for Quality Assurance; NHSN = National Healthcare Safety

Network; NQF = National Quality Forum; OHSU = Oregon Health and Science University; OPA = U.S. Office of

Population Affairs; TJC = The Joint Commission.

A.5

Exhibit A.2. 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult

Core Set)

NQF #

Measure

steward Measure name Data collection method

Primary Care Access and Preventive Care

0032 NCQA Cervical Cancer Screening (CCS-AD)

Administrative, hybrid, or

EHR

0033 NCQA Chlamydia Screening in Women Ages 21–24 (CHL-AD) Administrative or EHR

0039 NCQA Flu Vaccinations for Adults Ages 18 to 64 (FVA-AD) Survey

0418/0418e CMS

Screening for Depression and Follow-Up Plan: Age 18

and Older (CDF-AD)

Administrative or EHR

2372 NCQA Breast Cancer Screening (BCS-AD) Administrative or EHR

Not endorsed NCQA Adult Body Mass Index Assessment (ABA-AD) Administrative or hybrid

Maternal and Perinatal Health

0469/0469e TJC PC-01: Elective Delivery (PC01-AD) Hybrid or EHR

1517* NCQA

Prenatal and Postpartum Care: Postpartum Care (PPC-

AD)

Administrative or hybrid

2902 OPA

Contraceptive Care – Postpartum Women Ages 21–44

(CCP-AD)

Administrative

2903/2904 OPA

Contraceptive Care – All Women Ages 21–44 (CCW-

AD)

Administrative

Care of Acute and Chronic Conditions

0018 NCQA Controlling High Blood Pressure (CBP-AD)

Administrative, hybrid, or

EHR

0057 NCQA

Comprehensive Diabetes Care: Hemoglobin A1c

(HbA1c) Testing (HA1C-AD)

Administrative or hybrid

0059 NCQA

Comprehensive Diabetes Care: Hemoglobin A1c

(HbA1c) Poor Control (>9.0%) (HPC-AD)

Administrative, hybrid, or

EHR

0272 AHRQ

PQI 01: Diabetes Short-Term Complications Admission

Rate (PQI01-AD)

Administrative

0275 AHRQ

PQI 05: Chronic Obstructive Pulmonary Disease

(COPD) or Asthma in Older Adults Admission Rate

(PQI05-AD)

Administrative

0277 AHRQ PQI 08: Heart Failure Admission Rate (PQI08-AD) Administrative

0283 AHRQ

PQI 15: Asthma in Younger Adults Admission Rate

(PQI15-AD)

Administrative

1768 NCQA Plan All-Cause Readmissions (PCR-AD) Administrative

1800 NCQA Asthma Medication Ratio: Ages 19–64 (AMR-AD) Administrative

2082/3210e HRSA HIV Viral Load Suppression (HVL-AD) Administrative or EHR

2371* NCQA

Annual Monitoring for Patients on Persistent

Medications (MPM-AD)

Administrative

Behavioral Health Care

0004 NCQA

Initiation and Engagement of Alcohol and Other Drug

Abuse or Dependence Treatment (IET-AD)

Administrative or EHR

0027 NCQA

Medical Assistance with Smoking and Tobacco Use

Cessation (MSC-AD)

Survey

Exhibit A.2. (continued)

A.6

NQF #

Measure

steward Measure name Data collection method

0105 NCQA Antidepressant Medication Management (AMM-AD) Administrative or EHR

0576 NCQA

Follow-Up After Hospitalization for Mental Illness: Age

18 and Older (FUH-AD)

Administrative

1932 NCQA

Diabetes Screening for People With Schizophrenia or

Bipolar Disorder Who Are Using Antipsychotic

Medications (SSD-AD)

Administrative

2605 NCQA

Follow-Up After Emergency Department Visit for

Alcohol and Other Drug Abuse or Dependence (FUA-

AD)

Administrative

2605 NCQA

Follow-Up After Emergency Department Visit for Mental

Illness (FUM-AD)

Administrative

2607 NCQA

Diabetes Care for People with Serious Mental Illness:

Hemoglobin A1c (HbA1c) Poor Control (>9.0%)

(HPCMI-AD)

Administrative or hybrid

2940 PQA

Use of Opioids at High Dosage in Persons Without

Cancer (OHD-AD)

Administrative

Not

endorsed**

NCQA

Adherence to Antipsychotic Medications for Individuals

with Schizophrenia (SAA-AD)

Administrative

3389 PQA

Concurrent Use of Opioids and Benzodiazepines (COB-

AD)

Administrative

Experience of Care

Not

endorsed***

NCQA

Consumer Assessment of Healthcare Providers and

Systems (CAHPS®) Health Plan Survey 5.0H, Adult

Version (Medicaid) (CPA-AD)

Survey

More information on 2019 Updates to the Child and Adult Core Health Care Quality Measurement Sets is available at

https://www.medicaid.gov/federal-policy-guidance/downloads/cib112018.pdf.

*This measure is no longer endorsed by NQF.

**The Adult Core Set includes the NCQA version of the measure, which is adapted from the CMS measure (NQF

#1879).

***The Adult Core Set includes the NCQA version of the measure, which is adapted from the AHRQ measure (NQF

#0006).

The FUA-AD and FUM-AD measures were previously included in the Adult Core Set as a single measure

(FUA/FUM-AD). For the 2019 Adult Core Set, they are included as two separate measures.

AHRQ = Agency for Healthcare Research & Quality; CMS = Centers for Medicare & Medicaid Services; EHR =

Electronic Health Record; HRSA = Health Resources and Services Administration; NCQA = National Committee for

Quality Assurance; NQF = National Quality Forum; OPA = U.S. Office of Population Affairs; PQA = Pharmacy Quality

Alliance; TJC = The Joint Commission.

A.7

Exhibit A.3. Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set), 2012–2019

NQF #

Measure

Steward

Measure Name 2012 2013 2014 2015 2016 2017 2018 2019

Primary Care Access and Preventive Care

0024 NCQA

Weight Assessment and Counseling for Nutrition

and Physical Activity for Children/Adolescents –

Body Mass Index Assessment for

Children/Adolescents (WCC-CH)

X X X X X X X X

0033 NCQA

Chlamydia Screening in Women Ages 16–20

(CHL-CH)

X X X X X X X X

0038 NCQA Childhood Immunization Status (CIS-CH) X X X X X X X X

0418/0418e CMS

Screening for Depression and Follow-Up Plan:

Ages 12–17 (CDF-CH)

-- -- -- -- -- -- X X

1392 NCQA

Well-Child Visits in the First 15 Months of Life

(W15-CH)

X X X X X X X X

1407 NCQA Immunizations for Adolescents (IMA-CH) X X X X X X X X

1448* OHSU

Developmental Screening in the First Three

Years of Life (DEV-CH)

X X X X X X X X

1516 NCQA

Well-Child Visits in the Third, Fourth, Fifth and

Sixth Years of Life (W34-CH)

X X X X X X X X

1959 NCQA

Human Papillomavirus Vaccine for Female

Adolescents (HPV-CH)

-- X X X X -- -- --

NA NCQA Adolescent Well-Care Visits (AWC-CH) X X X X X X X X

NA NCQA

Child and Adolescents’ Access to Primary Care

Practitioners (CAP-CH)

X X X X X X X X

Maternal and Perinatal Health

0139 CDC

Pediatric Central Line-Associated Bloodstream

Infections (CLABSI-CH)

X X X X X X X X

0471 TJC PC-02: Cesarean Birth (PC02-CH)

X X X X X X X X

1360 CDC

Audiological Diagnosis No Later Than 3 Months

of Age (AUD-CH)

-- -- -- -- X X X X

Exhibit A.3. (continued)

A.8

NQF #

Measure

Steward

Measure Name 2012 2013 2014 2015 2016 2017 2018 2019

1382 CDC

Live Births Weighing Less Than 2,500 Grams

(LBW-CH)

X X X X X X X X

1391* NCQA Frequency of Ongoing Prenatal Care (FPC-CH)

X X X X X X -- --

1517* NCQA

Prenatal and Postpartum Care: Timeliness of

Prenatal Care (PPC-CH)

X X X X X X X X

2902 OPA

Contraceptive Care – Postpartum Women Ages

15–20 (CCP-CH)

-- -- -- -- -- X X X

2903/2904 OPA

Contraceptive Care – All Women Ages 15–20

(CCW-CH)

-- -- -- -- -- -- X X

No current

measure

steward

Behavioral Health Risk Assessment (for

Pregnant Women) (BHRA-CH)

-- X X X X X -- --

Care of Acute and Chronic Conditions

0002* NCQA

Appropriate Testing for Children with Pharyngitis

(CWP-CH)

X X -- -- -- -- -- --

0060* NCQA

Annual Pediatric Hemoglobin A1C Testing

(PA1C-CH)

X X -- -- -- -- -- --

0657 AAOH-HNSF

Otitis Media with Effusion –Avoidance of

Inappropriate Systemic Antimicrobials in

Children: Ages 2-12 (OME-CH)

X -- -- -- -- -- -- --

1381*

Alabama

Medicaid

Annual Percentage of Asthma Patients 2

Through 20 Years Old with One of More

Asthma-Related Emergency Room Visits

(ASMER-CH)

X X -- -- -- -- -- --

1799* NCQA

Medication Management for People with Asthma

(MMA-CH)

-- X X X X X -- --

1800 NCQA

Asthma Medication Ratio: Ages 5–18 (AMR-

CH)

-- -- -- -- -- -- X X

NA NCQA

Ambulatory Care: Emergency Department (ED)

Visits (AMB-CH)

X X X X X X X X

Exhibit A.3. (continued)

A.9

NQF #

Measure

Steward

Measure Name 2012 2013 2014 2015 2016 2017 2018 2019

Behavioral Health Care

0108 NCQA

Follow-Up Care for Children Prescribed

Attention- Deficit/Hyperactivity Disorder (ADHD)

Medication (ADD-CH)

X X X X X X X X

0576 NCQA

Follow-Up After Hospitalization for Mental

Illness: Ages 6–17 (FUH-CH)

X X X X X X X X

1365 PCPI

Child and Adolescent Major Depressive

Disorder: Suicide Risk Assessment (SRA-CH)

-- -- -- X X X -- --

2801 NCQA

Use of First-Line Psychosocial Care for Children

and Adolescents on Antipsychotics (APP-CH)

-- -- -- -- -- X X X

NA NCQA

Use of Multiple Concurrent Antipsychotics in

Children and Adolescents (APC-CH)

-- -- -- -- X X X X

Dental and Oral Health Services

2508*

DQA

(ADA)

Dental Sealants for 6–9 Year-Old Children at

Elevated Caries Risk (SEAL-CH)

-- -- -- X X X X X

NA CMS

Percentage of Eligibles Who Received

Preventive Dental Services (PDENT-CH)

X X X X X X X X

NA CMS

Percentage of Eligibles That Received Dental

Treatment Services (TDENT-CH)

X X X -- -- -- -- --

Experience of Care

NA NCQA

Consumer Assessment of Healthcare Providers

and Systems (CAHPS®) Health Plan Survey

5.0H – Child Version Including Medicaid and

Children with Chronic Conditions Supplemental

Items (CPC-CH)

X X X X X X X X

X = Included in Child Core Set; -- = Not Included in Child Core Set.

AAO-HNSF = American Academy of Otolaryngology-Head and Neck Surgery; AMA = American Medical Association; CDC = Centers for Disease Control and

Prevention; CMS = Centers for Medicare & Medicaid Services; DQA (ADA) = Dental Quality Alliance (American Dental Association); NA = Measure is not NQF

endorsed; NCQA = National Committee for Quality Assurance; NQF = National Quality Forum; OHSU = Oregon Health and Science University; OPA = U.S. Office

of Population Affairs; PCPI = Physician Consortium for Performance Improvement; TJC = The Joint Commission.

More information on 2019 Updates to the Child and Adult Core Health Care Quality Measurement Sets is available at https://www.medicaid.gov/federal-policy-

guidance/downloads/cib112018.pdf.

*This measure is no longer endorsed by NQF.

Exhibit A.3. (continued)

A.10

The Screening for Depression and Follow-Up Plan: Ages 12 –17 measure was added to the 2018 Child Core Set to align with the Adult Core Set and replace the

Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment measure as a broader measure of behavioral health.

The stand-alone HPV Vaccine for Female Adolescents measure was retired by the measure steward, and added to the Immunizations for Adolescents measure

beginning with the 2017 Child Core Set.

The California Maternal Quality Care Collaborative Cesarean Rate for Nulliparous Singleton Vertex measure was replaced by The Joint Commission PC-02:

Cesarean Birth measure beginning with the 2014 Child Core Set.

The Audiological Diagnosis No Later Than 3 Months of Age measure was added to the 2016 Child Core Set due to opportunities for quality improvement on the

measure and its alignment with the electronic health record incentive program.

The Frequency of Ongoing Prenatal care measure was retired from the Child Core Set in 2018 because it does not assess the content of the prenatal care visit.

The Contraceptive Care – Postpartum Women Ages 15–20 measure was added to the 2017 Child Core Set because it measures the provision of contraception to

mothers in the postpartum period, which can help women space pregnancies to their desired interpregnancy interval and help to improve future birth outcomes.

The Contraceptive Care – All Women Ages 15–20 measure was added to the 2018 Child Core Set to assess access to contraceptive care, which has an

important role in promoting health equity.

The Behavioral Health Risk Assessment (for Pregnant Women) measure was removed from the Child Core Set in 2018 due to implementation and data collection

challenges. AMA-PCPI was the measure steward for the 2013-2016 Child Core Sets; the measure had no steward for the 2017 Child Core Set.

The Appropriate Testing for Children with Pharyngitis measure was retired from the Child Core Set in 2014 because the clinical evidence for the measure is

obsolete.

The Annual Pediatric Hemoglobin A1C Testing measure was retired from the Child Core Set in 2014 because it affects a small number of children, has a weak

evidence base, and was approaching the improvement ceiling.

The Otitis Media with Effusion – Avoidance of Inappropriate Systemic Antimicrobials in Children (ages 2-12) measure was retired from the Child Core Set in 2013

because of significant state reporting challenges. AMA-PCPI was the measure steward for the 2012 Child Core Set.

The Annual Percentage of Asthma Patients 2 Through 20 Years Old with One or More Asthma-Related Emergency Room Visits measure was retired from the

Child Core Set in 2014 due to data quality concerns and the lack of a measure steward.

Beginning with the 2018 Child Core Set, the Asthma Medication Ratio: Ages 5–18 measure replaces the Medication Management for People with Asthma

measure, which was included in the 2013-2017 Child Core Sets.

The age group for the Follow-Up After Hospitalization for Mental Illness measure changed from ages 6 to 20 to ages 6 to 17 for the 2019 Child Core Set.

The Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment measure was added to the 2015 Child Core Set to target a high prevalence

mental health condition that has severe consequences without appropriate treatment. The measure was removed from the Child Core Set in 2018 because of the

need for a broader measure of behavioral health.

The Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics measure was added to the 2017 Child Core Set to promote the use of

nonpharmacologic, evidence-informed approaches to the treatment of mental and behavioral health problems of Medicaid and CHIP insured children on

psychotropic medications.

The Use of Multiple Concurrent Antipsychotics in Children and Adolescents measure was added to the 2016 Child Core Set to target inappropriate prescribing of

antipsychotic medications, which may have adverse health effects.

The Dental Sealants for 6–9 Year-Old Children at Elevated Caries Risk measure was added to the 2015 Child Core Set because it is linked to improved oral

health outcomes and responds to a legislative mandate to measure the use of dental sealants in this age group.

The Percentage of Eligibles That Received Dental Treatment Services measure was retired from the Child Core Set in 2015 because it is not an effective tool for

quality improvement; it is unclear if an increase or a decrease in the rate is desirable, and therefore the results are not actionable.

A.11

Exhibit A.4. Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set), 2013–2019

NQF #

Measure

Steward

Measure Name 2013 2014 2015 2016 2017 2018 2019

Primary Care Access and Preventive Care

0032 NCQA Cervical Cancer Screening (CCS-AD) X X X X X X X

0033 NCQA

Chlamydia Screening in Women Ages 21–24 (CHL-

AD)

X X X X X X X

0039 NCQA

Flu Vaccinations for Adults Ages 18 to 64

(FVA-AD)

X X X X X X X

0418/0418e CMS

Screening for Depression and Follow-Up Plan: Age 18

and Older (CDF-AD)

X X X X X X X

2372 NCQA Breast Cancer Screening (BCS-AD) X X X X X X X

NA NCQA Adult Body Mass Index Assessment (ABA-AD) X X X X X X X

Maternal and Perinatal Health

0469/0469e TJC PC-01: Elective Delivery (PC01-AD) X X X X X X X

0476 TJC PC-03: Antenatal Steroids (PC03-AD)

X X X X X X --

1517* NCQA

Prenatal and Postpartum Care: Postpartum Care

(PPC-AD)

X X X X X X X

2902 OPA

Contraceptive Care – Postpartum Women

Ages 21–44 (CCP-AD)

-- -- -- -- X X X

2903/2904 OPA

Contraceptive Care – All Women Ages 21–44

(CCW-AD)

-- -- -- -- -- X X

Care of Acute and Chronic Conditions

0018 NCQA Controlling High Blood Pressure (CBP-AD) X X X X X X X

0057 NCQA

Comprehensive Diabetes Care: Hemoglobin

A1c (HbA1c) Testing (HA1C-AD)

X X X X X X X

0059 NCQA

Comprehensive Diabetes Care: Hemoglobin

A1c (HbA1c) Poor Control (>9.0%) (HPC-

AD)

-- -- X X X X X

Exhibit A.4. (continued)

A.12

NQF #

Measure

Steward

Measure Name 2013 2014 2015 2016 2017 2018 2019

0063* NCQA

Comprehensive Diabetes Care: LDL-C

Screening (LDL-AD)

X X -- -- -- -- --

0272 AHRQ

PQI 01: Diabetes Short-Term Complications

Admission Rate (PQI01-AD)

X X X X X X X

0275 AHRQ

PQI 05: Chronic Obstructive Pulmonary

Disease (COPD) or Asthma in Older Adults

Admission Rate (PQI05-AD)

X X X X X X X

0277 AHRQ

PQI 08: Heart Failure Admission Rate

(PQI08-AD)

X X X X X X X

0283 AHRQ

PQI 15: Asthma in Younger Adults Admission

Rate (PQI15-AD)

X X X X X X X

0403* NCQA Annual HIV/AIDS Medical Visit (HMV-AD)

X -- -- -- -- -- --

1768 NCQA Plan All-Cause Readmissions (PCR-AD) X X X X X X X

1800 NCQA

Asthma Medication Ratio: Ages 19–64

(AMR-AD)

-- -- -- -- -- X X

2082/3210e HRSA HIV Viral Load Suppression (HVL-AD) -- X X X X X X

2371* NCQA

Annual Monitoring for Patients on Persistent

Medications (MPM-AD)

X X X X X X X

Behavioral Health Care

0004 NCQA

Initiation and Engagement of Alcohol and Other Drug

Abuse or Dependence Treatment

(IET-AD)

X X X X X X X

0027 NCQA

Medical Assistance with Smoking and Tobacco

Use Cessation (MSC-AD)

X X X X X X X

0105 NCQA

Antidepressant Medication Management (AMM-

AD)

X X X X X X X

0576 NCQA

Follow-Up After Hospitalization for Mental Illness: Age

18 and Older (FUH-AD)

X X X X X X X

1932 NCQA

Diabetes Screening for People With Schizophrenia

or Bipolar Disorder Who Are Using Antipsychotic

Medications (SSD-AD)

-- -- -- X X X X

Exhibit A.4. (continued)

A.13

NQF #

Measure

Steward

Measure Name 2013 2014 2015 2016 2017 2018 2019

2605 NCQA

Follow-Up After Emergency Department Visit for

Alcohol and Other Drug Abuse or Dependence

(FUA -AD)

-- -- -- -- X X X

2605 NCQA

Follow-Up After Emergency Department Visit for

Mental Illness (FUM-AD)

-- -- -- -- X X X

2607 NCQA

Diabetes Care for People with Serious Mental

Illness: Hemoglobin A1c (HbA1c) Poor Control

(>9.0%)

(HPCMI-AD)

-- -- -- -- X X X

2940 PQA

Use of Opioids at High Dosage in Persons Without

Cancer (OHD-AD)

-- -- -- X X X X

NA NCQA

Adherence to Antipsychotic Medications for Individuals

with Schizophrenia (SAA-AD)

X X X X X X X

3389 PQA

Concurrent Use of Opioids and Benzodiazepines

(COB-AD)

-- -- -- -- -- X X

Care Coordination

0648* AMA-PCPI

Timely Transmission of Transition Record

(Discharges from an Inpatient Facility to Home/Self

Care or Any Other Site of Care) (CTR-AD)

X X X X -- -- --

Experience of Care

NA NCQA

Consumer Assessment of Healthcare Providers and

Systems (CAHPS®) Health Plan Survey 5.0H, Adult

Version (Medicaid) (CPA-AD)

X X X X X X X

X = Included in Adult Core Set; -- = Not Included in Adult Core Set.

AHRQ = Agency for Healthcare Research & Quality; AMA-PCPI = American Medical Association-Physician Consortium for Performance Improvement; CMS =

Centers for Medicare & Medicaid Services; HRSA = Health Resources and Services Administration; NA = Measure is not NQF endorsed; NCQA = National

Committee for Quality Assurance; NQF = National Quality Forum; OPA = U.S. Office of Population Affairs; PQA = Pharmacy Quality Alliance; TJC = The Joint

Commission.

More information on 2019 Updates to the Child and Adult Core Health Care Quality Measurement Sets is available at

https://www.medicaid.gov/federal-policy-

guidance/downloads/cib112018.pdf.

*This measure is no longer endorsed by NQF.

The Antenatal Steroids measure was retired from the Adult Core Set in 2019 due to the low number of states reporting this measure and the challenges states

have described in collecting it.

Exhibit A.4. (continued)

A.14

The Contraceptive Care – Postpartum Women Ages 21–44 measure was added to the 2017 Adult Core Set because it measures the provision of contraception

to mothers in the postpartum period, which can help women space pregnancies to their desired interpregnancy interval and help to improve future birth outcomes.

The Contraceptive Care – All Women Ages 21–44 measure was added to the 2018 Adult Core Set to assess access to contraceptive care, which has an

important role in promoting health equity.

The Comprehensive Diabetes Care: LDL-C Screening measure was replaced by the Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control

(>9.0%) measure beginning with the 2015 Adult Core Set. The Comprehensive Diabetes Care: LDL-C Screening measure was retired from the Adult Core Set

because clinical guidelines underpinning this measure were in flux and because NCQA removed it from HEDIS 2015. The Comprehensive Diabetes Care:

Hemoglobin A1c Poor Control (>9.0%) measure addresses the prevalent condition of diabetes and facilitates state efforts to drive quality improvement on the risk

factor of poor HbA1c control.

The Annual HIV Medical Visit measure was replaced by the HIV Viral Load Suppression measure beginning with the 2014 Adult Core Set. The Annual HIV

Medical Visit measure lost NQF endorsement after the 2013 Adult Core Set was published. The HIV Viral Load Suppression measure is a regularly collected

clinical indicator that is predictive of overall outcomes.

The Asthma Medication Ratio: Ages 19–64 measure was added to the 2018 Adult Core Set and aligns with changes made to the 2018 Child Core Set.

The age group for the Follow-Up After Hospitalization for Mental Illness measure changed from age 21 and older to age 18 and older for the 2019 Adult Core Set.

Two measures focused on quality of care for adults with substance use disorders and/or mental health disorders were added to the 2016 Adult Core Set: (1)

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications focuses on the identification of cardiovascular

disease, a leading cause of morbidity and mortality in this population; and (2) Use of Use of Opioids at High Dosage in Persons Without Cancer is a measure of

potential overuse that addresses the epidemic of narcotic morbidity and mortality.

The Follow-Up After Emergency Department Visit for Mental Illness or Alcohol and Other Drug Abuse or Dependence (FUA/FUM-AD) measure was added to the

2017 Adult Core Set because it addresses priority areas of access and follow-up of care for adults with mental health or substance use disorders. In the 2017 and

2018 Adult Core Sets, this was included as a single measure (FUA/FUM-AD). For the 2019 Adult Core Set, Follow-Up After Emergency Department Visit for

Alcohol and Other Drug Abuse or Dependence (FUA-AD) and Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD) are included as two

separate measures.

The Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) measure was added to the 2017 Adult Core Set

because it addresses chronic disease management for people with serious mental illness, and assesses integration of medical and behavioral services by

reinforcing shared accountability and linkage of medical and behavioral healthcare services.

The Adult Core Set includes the NCQA version of the Adherence to Antipsychotic Medications for Individuals with Schizophrenia measure, which is adapted from

the CMS measure (NQF #1879).

The Concurrent Use of Opioids and Benzodiazepines measure was added to the 2018 Adult Core Set because it addresses early opioid use and polypharmacy.

The Timely Transmission of Transition Record measure was retired from the Adult Core Set in 2017 due to the low number of states reporting this measure, a

decrease in the number of states reporting over time, and the challenges states have described in collecting it.

The Adult Core Set includes the NCQA version of the CAHPS® Health Plan Survey 5.0H, Adult Version (Medicaid) measure, which is adapted from the AHRQ

measure (NQF #0006).

Appendix B

Summary of 2020 Core Set Annual Review Workgroup

Discussion of Measures Not Recommended

For Removal or Addition

This page has been left blank for double-sided copying.

B.3

This appendix summarizes the discussion of measures suggested but not recommended for

removal from or addition to the 2020 Child and Adult Core Sets. The discussion took place

during the in-person Workgroup meeting May 7-9. The summary is organized by domain. For

more information about the measures discussed but not recommended for removal or addition,

please refer to Exhibit B.1 at the end of this appendix, including the measure name, measure

steward, NQF # (if endorsed), measure description, and data collection method.

Primary Care Access and Preventive Care

In the Primary Care Access and Preventive Care domain, the Workgroup first discussed

immunization measures, including the Flu Vaccinations for Adults Ages 18 to 64 (FVA-AD)

measure suggested for removal from the Adult Core Set and four immunization measures

proposed for addition (Flu Vaccinations for Adults Age 65 and Older; Influenza Immunization;

Adult Immunization Status; Prenatal Immunization Status). The FVA-AD measure was

suggested for removal because of the high cost of the CAHPS survey and the fact that it only

covers flu vaccinations while other measures include additional immunizations and wider age

ranges. The Influenza Immunization measure was suggested to replace the FVA-AD measure

because it is lower cost and more comparable across diverse populations, according to the

Workgroup member who suggested it. The Adult Immunization Status measure was suggested

for addition because it includes more vaccines than the current immunization measure (FVA-

AD) and would help states monitor appropriate adult immunization use beyond influenza.

Workgroup members suggested adding the Prenatal Immunization Status measure because

vaccinations for this population are not currently being measured in the Core Set, and there are

substantial disparities in prenatal immunization levels.

The Workgroup discussed the accuracy and reliability of the data needed for the immunization

measures, many of which rely on patient recall or administrative data that may be incomplete for

people who cycle in and out of Medicaid plans. Furthermore, because influenza vaccines can be

administered in a variety of settings, data on them might be incomplete. Workgroup members

noted that while all states have immunization registries, there is considerable variability in their

completeness. In the case of the Prenatal Immunization Status measure, Workgroup members

acknowledged its importance and strong connection to improved outcomes, but had concerns

about the feasibility of the new data collection method

and were reluctant to recommend a first-

year HEDIS measure that might not be ready for state reporting.

For the Lead Screening in Children and HIV Screening measures, Workgroup members

deliberated whether these measures were more appropriate for public health surveillance

programs rather than for Medicaid quality measurement. Data completeness concerns were also

raised for both measures, especially in states where there is no linkage between state public

health and Medicaid data. For the Body Mass Index Screening and Follow-Up Plan and Follow-

Up with Patient Family After Developmental Screening measures, Workgroup members

acknowledged these are areas of high interest but had concerns whether the proposed measures

would promote quality improvement. In addition, there were concerns about the burden of the

The Prenatal Immunization Status and Adult Immunization Status measures are specified for the Electronic

Clinical Data Systems (ECDS) data collection method, which includes data from administrative claims, electronic

health records, case management systems, and health information exchanges/clinical registries.

B.4

medical record reviews required to calculate these measures. For the Colorectal Cancer

Screening measure, Workgroup members acknowledged that such screenings are highly effective

and associated with reduced costs. However, they also restated concerns about recommending a

HEDIS measure that had not yet been used for the Medicaid population and raised concerns

about the measure’s extended look-back period.

Maternal and Perinatal Health

A Workgroup member suggested the PC-01: Elective Delivery (PC01-AD) measure for removal

from the Adult Core Set and suggested an existing Child Core Set measure, PC-02: Cesarean

Birth (PC02-CH), as a substitute. The Workgroup acknowledged that early elective induction, in

the absence of medical necessity, is a driver of cesarean rates and neonatal intensive care unit

utilization. Workgroup members commented that few states are reporting the PC01-AD measure

and state representatives noted the challenges with collecting the measure, including that the

numerator is not available in claims data, so medical record review or vital records linkage is

required (and some have found that vital records linkage does not provide the information

needed to calculate the measure). Some Workgroup members questioned whether reporting on

the rate of elective deliveries in the Core Set allows for action by states, and furthermore,

whether outliers on the measure should be regulated outside a quality measurement program.

They also noted that other perinatal measures have demonstrated more unwarranted variation and

impact a greater number of beneficiaries. However, several Workgroup members shared a

concern of slippage in performance if the PC01-AD measure is removed from the Adult Core Set

and noted that because Medicaid pays for such a high percentage of births, measures are an

important indicator of priorities for quality of care, and this issue is a high priority.

A Workgroup member suggested removal of the Contraceptive Care – Postpartum Women Ages

21–44 (CCP-AD) measure because another measure in the Core Set, the Contraceptive Care –

All Women Ages 15–20 (CCP-CH), addresses the same measure concept. It was noted that only

the ages 21–44 portion of the measure was suggested for removal and not the age 15–20

measure, which was concerning to the Workgroup. It was also clarified that the postpartum

population cannot be parsed out from the Contraceptive Care – All Women (CCW-CH/AD)

measure in the Child and Adult Core Sets. The Workgroup felt it important to have a measure for

postpartum women, as effective postpartum contraception is a method to increase birth spacing,

which is related to low birthweight and other poor outcomes. A Workgroup member also noted

that maintaining the measure in the Core Set could drive states to resolve payment issues around

insertion of long-acting reversible methods of contraception. A public commenter noted that

CMCS, CDC, and the Office of Population Affairs partnered to support states in calculating,

reporting, and using the Contraceptive Care measures to track access and drive improvements.

The PC-05: Exclusive Breast Milk Feeding measure was suggested for addition to the Core Sets

as there is evidence that breast milk feeding improves life course and reduces disparities. The

Workgroup member noted that the measure can be used to hold systems accountable with the

understanding that the goal is not a rate of 100 percent. Exclusive breastfeeding is a goal of the

World Health Organization, U.S. Department of Health and Human Services, American

Academy of Pediatrics, and the American College of Obstetricians and Gynecologists.

Workgroup members noted that it is a non-medical measure that can be used to address

disparities and capture data about intended breastfeeding, allowing states to see where

B.5

interventions are needed for certain hospitals and populations. Workgroup members questioned

whether there is anything built into the measure to take into account cultural preferences,

medications the mother is taking, or breastfeeding attempts, which may limit a mother’s ability

to breastfeed exclusively or at all in the first few days of life. The Workgroup shared concerns

about the title of the measure and the signal it would send if it was added to the Core Set. Finally,

one Workgroup member noted that the data collection method is medical record review, which

could make it difficult for states to report.

Workgroup members suggested the Prenatal Depression Screening and Follow-Up measure for

addition to the Core Sets because prenatal depression can be treated successfully if treated early;

the measure could be used to assess the content of prenatal care and to improve outcomes for

mothers and babies. A Workgroup member suggested addition of the Postpartum Depression

Screening and Follow-Up measure to capture maternal well-being and newborn development.

The measures address a gap area, could address disparities, and might incentivize meeting

minimum thresholds for screening. It was noted that these measures are particularly important

because (1) access to behavioral health care for the Medicaid population is essential; and (2)

women are especially vulnerable for depression in the perinatal period, which can have a large

impact on their lives and life of their child. It was also noted that some women do not return for

their postpartum appointment, so a Workgroup member noted that the postpartum measure will

pick up screens done at newborn appointments, which might be the only opportunity to reach the

mother.

The Prenatal Depression Screening and Follow-Up and Postpartum Depression Screening and

Follow-Up measures are proposed for addition to HEDIS 2020 and are specified for the ECDS

data collection method. Workgroup members shared concern with the measures being new and

untested at the state level as well as using a new data collection method. Although Workgroup

members noted the appeal and importance of having a measure that incentivizes documenting

postpartum screening in the mother’s chart rather than the infant’s, there was also concern about

being able to capture the infant’s date of birth without linking claims or vital records to the

mother’s record.

Care of Acute and Chronic Conditions

A Workgroup member suggested removal of the HIV Viral Load Suppression (HVL-AD)

measure from the Adult Core Set given the low uptake by states. Workgroup members

acknowledged the challenges of obtaining access to laboratory data on viral load suppression,

which one member attributed in part to the stigmatization of HIV. They expressed concerns that

dropping the measure might signal that CMCS is deprioritizing HIV and serve only to increase

stigmatization. Workgroup members discussed state progress on developing mechanisms to

report the measure, including through a learning collaborative jointly sponsored by CDC, HRSA,

and CMCS, which may increase the number of states able to report the measure in the future.

The Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis and Appropriate

Treatment for Upper Respiratory Infection measures assess appropriate use of antibiotics for

respiratory infections with the goal of improving patient safety. Workgroup members noted the

importance of these measures for combating inappropriate antibiotic use, which recently has

been affected by the rise in telemedicine. However, Workgroup members raised concerns about

B.6

the measure methodologies, including whether these conditions are coded accurately in

administrative data, and whether changes in coding practices could be mistaken for quality

improvement.

The Transcranial Doppler Ultrasonography Screening for Children with Sickle Cell Anemia

measure was one of two measures suggested for improving quality of care for children with

sickle cell anemia. This measure was suggested because it has the potential to address disparities

for a population at early risk for stroke. When comparing the two sickle cell measures,

Workgroup members felt that the Appropriate Antibiotic Prophylaxis measure was the more

actionable of the two and had more opportunities for improvement.

The Proportion of Days Covered: Antiretroviral Medications measure was suggested for

addition because viral load can be reduced if antiretrovirals are taken regularly, whereas lack of

compliance can lead to antiretroviral resistance. Workgroup members raised questions about how

the specifications handle pre-exposure prophylaxis and whether an HIV diagnosis is required for

an individual to be included in the measure-eligible population. The measure steward clarified

that the measure is not intended to capture prophylaxis adherence. Although it was suggested to

replace the HIV Viral Load Suppression measure, Workgroup members did not recommend it as

a replacement measure.

The Statin Therapy for the Prevention and Treatment of Cardiovascular Disease measure was

suggested for addition given the high prevalence of cardiovascular disease and the relative

availability and affordability of statins. Discussion of the measure centered on concerns that the

measure assessed whether a statin was ordered, rather than whether it was filled or taken. As

with other EHR and registry-based measures, Workgroup members also raised concerns about

feasibility due to limited access to the necessary data.

Behavioral Health Care

A Workgroup member suggested removal of the Medical Assistance with Smoking and Tobacco

Use Cessation (MSC-AD) measure from the Adult Core Set, because of low state uptake and the

high cost of conducting the CAHPS survey. Workgroup members noted that there are other

surveys and measures that monitor tobacco use. One concern with the MSC-AD measure is that

it does not ask about vaping, but rather leaves the question open for interpretation. The Tobacco

Use: Screening and Cessation Intervention measure was suggested as a potential replacement for

the MSC-AD measure, but Workgroup members raised similar concerns about the absence of

vaping from the measure specifications. Other members acknowledged that tobacco use is a large

public health issue, and that the Workgroup should not reject these measures solely because they

do not currently include vaping. Workgroup members also emphasized that tobacco cessation

education or other activities might occur outside the primary care setting, and that the MSC-AD

measure might give a broader perspective on those services.

A Workgroup member suggested the addition of the Preventive Care and Screening: Unhealthy

Alcohol Use: Screening and Brief Counseling measure to address gaps in assessing alcohol

screening and brief intervention among non-alcohol-dependent adults. This topic is a high

priority for some states, because it addresses gaps in alcohol screening, which is especially

relevant for pregnant women. Workgroup members noted that this measure is important because

B.7

there is a lack of accountability for alcohol screening among providers. However, Workgroup

members cited lack of specificity related to the screening tool as a weakness of the measure.

Further, one Workgroup member noted that the field of addiction medicine is moving away from

labeling people as having “problematic alcohol use.”

The Workgroup discussed, but did not recommend, three measures related to opioid use: (1) Use

of Opioids from Multiple Providers in Persons without Cancer, (2) Continuity of

Pharmacotherapy for Opioid Use Disorder, and (3) Pharmacotherapy for Opioid Use Disorder.

The first measure was suggested because it could be used to assess the effectiveness of state

initiatives to address the opioid epidemic. However, Workgroup members raised concerns about

underreporting, as individuals might pay out-of-pocket for opioids. One state representative

noted that they are currently calculating the measure but not releasing the results because the

data are unreliable. The Workgroup member who suggested the Continuity of Pharmacotherapy

for OUD measure noted that it was a first step in measuring recovery and health outcomes in a

population at high risk for overdose and death. It could be used to address the gap in assessing

retention in care, which can serve as a proxy for recovery. Workgroup members noted that

measuring continuity of medication assisted treatment is important; however, it was noted that the

measure does not incorporate a therapy component. The Pharmacotherapy for OUD measure was

suggested because of evidence that pharmacotherapy can improve outcomes for individuals with

OUD. This measure looks only at new episodes, which differentiates it from the Continuity of

Pharmacotherapy measure. Workgroup members deliberated whether measuring the first

appointment versus continuity of care was more valuable for the Core Set, with some Workgroup

members saying both are critical to measure. Workgroup members deliberated the merits of each

of the measures and called on the measure stewards and technical experts to differentiate the two

measures for future consideration.

A Workgroup member suggested the Query of Prescription Drug Monitoring Program measure

to address gaps in tracking the use of Prescription Drug Monitoring Programs (PDMPs), which

can improve prescribing of controlled substances, a key step in controlling the opioid epidemic.

According to the Workgroup member, PDMP implementation is associated with decreased

opioid-related overdose deaths. Several Workgroup members from state Medicaid agencies

raised concerns about state laws preventing health plans from accessing the PDMP data. Another

member noted that as part of the Substance Use-Disorder Prevention That Promotes Opioid

Recovery and Treatment for Patients and Communities (SUPPORT) Act, there will be reporting

requirements related to PDMP beginning in 2023.

A Workgroup member suggested addition of the Follow-Up After High-Intensity Care for

Substance Use Disorder measure to address a gap in tracking receipt of follow-up care for SUD

treatment services. The member who suggested this measure noted that nationally, there is

greater investment in inpatient services for SUD, and less emphasis on continuity of care after

receiving inpatient services. Workgroup members expressed concern that because this measure

was proposed for HEDIS 2020, it was not yet ready for the Core Set; however, one member

noted that the concept of follow-up care had been tested for other measures.

B.8

Dental and Oral Health Services

The Workgroup discussion about the three dental and oral health measures considered for

addition to the Core Sets focused on whether the measures were ready for implementation by

state Medicaid programs. The Workgroup discussion on the Ambulatory Care Sensitive

Emergency Department Visits for Dental Caries in Children and the Follow-Up After Emergency

Department Visits for Dental Caries in Children focused on the results from states that have

tested or implemented the measure, as well as the relationship between the proposed measures

and the two existing dental measures in the Child Core Set. The Workgroup also raised questions

about the measure technical specifications, the sources of data needed to calculate the measure,

and whether this information would be readily available to all state Medicaid programs

(especially those with dental carve-outs). Although the Workgroup noted that the Adults with

Diabetes – Oral Evaluation measure would fill a gap in the Adult Core Set and is feasible

(having been implemented in one state’s incentive program), some members expressed concern

that the measure was still undergoing testing and that it might be more related to diabetes (for

which there are several other Adult Core Set measures) than oral health care. Nevertheless, states

expressed considerable interest in the three measures and some indicated they were planning to

share the measures with their staff.

Experience of Care

A Workgroup member suggested removing both CAHPS measures (CAHPS Health Plan Survey

5.0H –Child Version [CPC-CH] and CAHPS Health Plan Survey 5.0H – Adult Version [CPA-

AD]), citing poor state response rates, the high cost of administering the surveys, and the fact

that results may not be comparable across diverse populations. Many Workgroup members noted

that CAHPS is valuable because analysis of the data helps understand how patients experience

the care they receive. State representatives commented that they analyze CAHPS data, including

by health plan in managed care states, publicly post the findings, and use the results to inform

system and health plan performance improvement. Workgroup members were interested in

learning more about how CMCS uses the CAHPS data that states report for the Core Sets.

Two measures were considered for addition to the Core Set: Child Hospital CAHPS Survey and

Healthy Days Core Module – Health-Related Quality of Life. The Workgroup member who

suggested the Child Hospital CAHPS Survey measure noted that it would fill a gap by measuring

the experience of health care for children in hospitals. This measure has been considered in the

past, and it was recommended for additional testing (which is in process). A Workgroup member

noted that states are not actively using the measure. In addition, the survey is currently conducted

for all children and would need to be modified to be specific to the Medicaid population.

Furthermore, a Workgroup member noted that Medicaid programs have limited oversight over

hospital care, which may make it less appropriate for the Child Core Set.

The Workgroup member who suggested the Healthy Days Core Module – Health-Related

Quality of Life measure noted that although there is robust dialogue on how to measure and

improve an individual’s or a community’s social determinants of health, few measures have been

used or tested. This measure, however, has been available in the Behavioral Risk Factor

Surveillance System (BRFSS) since 1993 and is on the core module for that surveillance system.

Workgroup members noted concerns about the feasibility of reporting this measure specifically

B.9

for Medicaid beneficiaries because questions on respondents’ insurance status (including

Medicaid coverage) are optional in BRFSS and are not asked by all states.

Long-Term Services and Supports

Workgroup members discussed six LTSS measures that were suggested but not recommended

for addition to the 2020 Core Sets. All six measures were suggested to fill a gap in the 2019 Core

Sets, which contain no LTSS-focused measures. Workgroup members noted the importance of

adding LTSS measures, as this population comprises a large and growing share of Medicaid

beneficiaries and Medicaid expenditures and existing measures do not capture the unique needs

and experiences of this population.

Workgroup members discussed four measures as a group: (1) LTSS: Successful Transition After

Long-term Institutional Stay, (2) LTSS: Comprehensive Assessment and Update, (3) LTSS:

Comprehensive Care Plan and Update, and (4) LTSS: Reassessment/Care Plan Update After

Inpatient Discharge. These measures were developed on behalf of CMS as part of a suite of

LTSS measures and were designed specifically for states with managed LTSS delivery systems

(currently about 24 states). Measure developers noted that the measures could potentially be

adapted for use in states with fee-for-service delivery of LTSS. Workgroup members raised

concerns about the feasibility of collecting the data at the state level, especially because three of

the four measures require a case management record review. Workgroup members noted that the

first measure, LTSS: Successful Transition After Long-Term Institutional Stay, is an outcome

measure designed to assess progress in transitioning people to the community. However, the

other three measures focus on processes rather than on outcomes, such as completing

assessments, care plans, and care plan updates. For the two measures related to care plans, the

Workgroup questioned how the care plan elements were selected. Some states and home and

community based service (HCBS) waiver programs already have their own approaches to care

planning, and Workgroup members suggested that it could be difficult or undesirable to mandate

a single federal approach. Other Workgroup members responded that although the measures are

not perfect and might not exclusively represent outcomes, LTSS is a noted gap area, and there is

value in beginning to assess LTSS across states. They pointed out that states could use these four

measures to compare results across LTSS plans and care management entities to identify issues.

Additionally, there was discussion about the potential for using these four measures in the Health

Home Core Set or in Medicaid MLTSS contracts if they are not appropriate for the Child and

Adult Core Sets.

The next LTSS measure suggested but not recommended for addition to the 2020 Core Sets was

the Consumer Assessment of Healthcare Providers and Systems Home and Community Based

Services (HCBS CAHPS) survey, a cross-disability survey of the experience of HCBS

beneficiaries receiving LTSS. It is designed to facilitate comparisons across state Medicaid

HCBS programs throughout the country and is available for voluntary use as part of quality

assurance and improvement activities and public reporting. The survey instrument is designed to

be accessible to all populations of beneficiaries with disabilities, including individuals who are

nonverbal. The measure steward noted that 17 states have used the survey, including states

participating in the Testing Experience & Functional Tools (TEFT) demonstration and MLTSS

states. Because this is a new survey and the platform is still under development (scheduled to

become available in January 2020), Workgroup members voiced concern about adding it to the

B.10

2020 Core Sets. Members noted that data collection would need to be built into requirements for

MLTSS plans or fielded and funded by state Medicaid programs, which might be costly. Some

members also expressed concern about the survey length and how it could affect response rates,

since the survey covers 21 different areas and would likely take 30 minutes to an hour or more to

complete.

The final LTSS measure discussed but not recommended by the Workgroup was the Personal

Outcome Measures, a tool designed to ensure that services and supports are person-centered.

During a Personal Outcome Measures interview, 21 indicators are used to understand the

presence, importance, and achievement of outcomes involving choice, health, safety, social

capital, relationships, rights, goals, dreams, employment, and more. Measure developers noted

that people have been trained to use the tool in 45 states, and it is available for public use online.

Some states already incorporate the tool into person-centered plans and others use it with a

sample of their clients. Workgroup members voiced concerns about the high cost and time

intensiveness of collecting this data via in-depth interviews.

As part of the discussion on both the HCBS CAHPS survey and the Personal Outcome Measures

tool, Workgroup members agreed that, although collecting in-depth information is challenging at

the state level, it is important to find a way to better understand the experiences of people

receiving LTSS. Likewise, in light of the significant resources that states invest in LTSS, it is

important to provide feedback to the Medicaid program. One member suggested that to

accommodate the variety of data collection options states are exploring, CMCS could give states

flexibility in choosing which tool to use to assess LTSS. States could explain which tool they

used when reporting to CMCS.

Other Measures

Workgroup members suggested two other measures that were discussed but not recommended

for addition to the 2020 Core Sets. The Workgroup member who suggested the Continuity of

Insurance: Informed Participation measure for consideration noted that duration of coverage is a

current gap in the Core Sets and that it affects the completeness of other measures in

understanding the experience of all Medicaid and CHIP beneficiaries. Workgroup members

asked questions about the measure technical specifications, which were answered by the measure

steward, and noted that the Core Set may not be the appropriate place for this measure. One

Workgroup member noted that this measure has not been used extensively, so it could be

beneficial for states to try it and see how it could be used for quality measurement and

improvement.

The Workgroup member who suggested the Health-Related Social Needs Screening measure

noted the growing evidence that addressing health-related social needs can help improve overall

health and well-being. The member commented that few measures are being used or tested to

enable state Medicaid programs to measure social needs. Many Workgroup members

emphasized the importance of measuring social determinants of health. However, it was noted

that CMS’s Center for Medicare & Medicaid Innovation is currently testing this measure, and as

a result, some Workgroup members were concerned that it is not ready for use in the Core Set.

There was also a question about whether states would want to use this tool or identify other tools

that achieve similar aims.

B.11

Exhibit B.1. Measures discussed by the 2020 Core Set Annual Review Workgroup but not recommended for removal or

addition, by domain

Measure name

Measure

steward NQF # Measure description

Data collection

method

Primary Care Access and Preventive Care

Discussed but not recommended for removal from the 2020 Core Set

Flu Vaccinations for Adults

Ages 18 to 64 (FVA-AD)

NCQA 0039

Percentage of beneficiaries ages 18 to 64 who received a

flu vaccination between July 1 of the measurement year

and the date when the Consumer Assessment of

Healthcare Providers and Systems (CAHPS) 5.0H Adult

Medicaid Survey was completed.

Survey (CAHPS 5.0H

Adult Medicaid

Survey)

Discussed but not recommended for addition to the 2020 Core Set

Lead Screening in

Children

NCQA Not endorsed

Percentage of children 2 years of age who had one or

more capillary or venous lead blood test for lead

poisoning by their second birthday.

Administrative or

hybrid

Follow-Up with Patient

Family After

Developmental Screening

AHRQ,

PMCoE

Not endorsed

Percentage of patients aged 6 months to 36 months

whose family received a follow-up discussion of

developmental screening results on the same day of the

screening visit.

EHR or medical record

review

Prenatal Immunization

Status

NCQA Not endorsed

Percentage of deliveries in the measurement period in

which women received influenza and tetanus, diphtheria

toxoids, and acellular pertussis (Tdap) vaccinations.

Three rates are reported: influenza, Tdap, and a

combination rate.

ECDS

Colorectal Cancer

Screening

NCQA 0034

Percentage of patients 50–75 years of age who had

appropriate screening for colorectal cancer.

Administrative or

hybrid

Flu Vaccinations for Adults

Age 65 and Older

NCQA 0039

Percentage of Medicare members 65 years of age and

older who received a flu vaccination between July 1 of

the measurement year and the date when the Medicare

CAHPS survey was completed.

Survey (this measure

is derived from the

Medicare CAHPS

Survey)

B..12

Measure name

Measure

steward NQF # Measure description

Data collection

method

Preventive Care and

Screening: Body Mass

Index Screening and

Follow-Up Plan

CMS 0421/0421e

Percentage of patients age 18 years and older with a

body mass index (BMI) documented during the current

encounter or during the previous 12 months AND with a

BMI outside of normal parameters, a follow-up plan is

documented during the encounter or during the previous

12 months of the current encounter. Normal Parameters:

Age 18 years and older BMI ≥ 18.5 and < 25 kg/m

Administrative or EHR

Adult Immunization Status NCQA Not endorsed

Percentage of adults 19 years and older who are up to

date on recommended routine vaccines for influenza;

tetanus and diphtheria (Td) or tetanus, diphtheria and

acellular pertussis (Tdap); herpes zoster; and

pneumococcal.

ECDS

HIV Screening CDC Not endorsed

Percentage of patients ages 15–65 who have been

tested for HIV within that age range.

EHR

Influenza Immunization PCPI 0041/0041e

Percentage of patients age 6 months and older seen for

a visit between October 1 and March 31 who received an

influenza immunization OR who reported previous receipt

of an influenza immunization.

Administrative or EHR

Maternal and Perinatal Health

Discussed but not recommended for removal from the 2020 Core Set

PC-01: Elective Delivery

(PC01-AD)

TJC 0469/0469e

Percentage of women with elective vaginal deliveries or

elective cesarean sections at ≥ 37 and < 39 weeks of

gestation completed. Lower rates are better for this

measure.

Hybrid or EHR

Contraceptive Care –

Postpartum Women Ages

21–44 (CCP-AD)

OPA 2902

Among women ages 21–44 who had a live birth, the

percentage that: (1) were provided a most effective or

moderately effective method of contraception within 3

and 60 days of delivery; (2) were provided a long-acting

reversible method of contraception within 3 and 60 days

of delivery.

Administrative

B.13

Measure name

Measure

steward NQF # Measure description

Data collection

method

Discussed but not recommended for addition to the 2020 Core Set

PC-05: Exclusive Breast

Milk Feeding

TJC 0480/0480e

Percentage of newborns that were exclusively fed breast

milk during the newborn’s entire hospitalization.

“Exclusive breast milk feeding” is defined as a newborn

receiving only breast milk and no other liquids or solids

except for drops or syrups consisting of vitamins,

minerals, or medicines.

EHR or chart review

Prenatal Depression

Screening and Follow-Up

NCQA Not endorsed

Percentage of deliveries in which women were screened

for clinical depression while pregnant and, if screened

positive, received follow-up care. Two rates are reported:

(1) depression screening: the percentage of deliveries in

which women were screened for clinical depression using

a standardized tool during pregnancy; and (2) follow-up

on positive screen: the percentage of deliveries in which

pregnant women received follow-up care within 30 days

of screening positive for depression.

ECDS

Postpartum Depression

Screening and Follow-Up

NCQA Not endorsed

Percentage of deliveries in which women were screened

for clinical depression during the postpartum period, and

if screened positive, received follow-up care. Two rates

are reported: (1) depression screening: percentage of

deliveries in which women were screened for clinical

depression using a standardized tool within 12 weeks (84

days) post-delivery; and (2) follow-up on positive screen:

percentage of deliveries in which women received follow-

up care within 30 days of screening positive for

depression.

ECDS

Care of Acute and Chronic Conditions

Discussed but not recommended for removal from the 2020 Core Set

HIV Viral Load

Suppression (HVL-AD)

HRSA 2082/3210e

Percentage of beneficiaries age 18 and older with a

diagnosis of human immunodeficiency virus (HIV) who

had an HIV viral load less than 200 copies/mL at last HIV

viral load test during the measurement year.

Administrative or EHR

B.14

Measure name

Measure

steward NQF # Measure description

Data collection

method

Discussed but not recommended for addition to the 2020 Core Set

Transcranial Doppler

Ultrasonography

Screening for Children

with Sickle Cell Anemia

QMETRIC–

University

of Michigan

2797

Percentage of children ages 2 through 15 years during

the measurement year and identified as having sickle cell

anemia who received at least one Transcranial Doppler

ultrasonography screening within a year.

Administrative

Proportion of Days

Covered: Antiretroviral

Medications

PQA Not endorsed

Percentage of individuals 18 years and older who met the

Proportion of Days Covered threshold of 90% for ≥ 3

antiretroviral medications during the measurement year.

Administrative

Statin Therapy for the

Prevention and Treatment

of Cardiovascular Disease

CMS Not endorsed

Percentage of the following patients—all considered at

high risk of cardiovascular events—who were prescribed

or were on statin therapy during the measurement period:

(1) adults age ≥ 21 years who were previously diagnosed

with or currently have an active diagnosis of clinical

atherosclerotic cardiovascular disease; OR (2) adults age

≥ 21 years who have ever had a fasting or direct low-

density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL

or were previously diagnosed with or currently have an

active diagnosis of familial or pure hypercholesterolemia;

OR (3) adults ages 40–75 with a diagnosis of diabetes

with a fasting or direct LDL-C level of 70–189 mg/dL.

EHR or registry

Avoidance of Antibiotic

Treatment for Acute

Bronchitis/Bronchiolitis

NCQA 0058

Percentage of episodes for members age 3 months and

older with a diagnosis of acute bronchitis/bronchiolitis

that did not result in an antibiotic dispensing event.

Administrative or EHR

Appropriate Treatment for

Upper Respiratory

Infection

NCQA 0069

Percentage of episodes for members 3 months of age

and older with a diagnosis of upper respiratory infection

that did not result in an antibiotic dispensing event.

Administrative or EHR

B.15

Measure name

Measure

steward NQF # Measure description

Data collection

method

Behavioral Health Care

Discussed but not recommended for removal from the 2020 Core Set

Medical Assistance with

Smoking and Tobacco

Use Cessation (MSC-AD)

NCQA 0027

The three components of this measure assess different

facets of providing medical assistance with smoking and

tobacco use cessation: (1) advising smokers and tobacco

users to quit: a rolling average represents the percentage

of beneficiaries age 18 and older who were current

smokers or tobacco users and who received advice to

quit during the measurement year; (2) discussing

cessation medications: a rolling average represents the

percentage of beneficiaries age 18 and older who were

current smokers or tobacco users and who discussed or

were recommended cessation medications during the

measurement year; and (3) discussing cessation

strategies: a rolling average represents the percentage of

beneficiaries age 18 and older who were current smokers

or tobacco users and who discussed or were provided

cessation methods or strategies during the measurement

year.

Survey (CAHPS 5.0H

Adult Medicaid

Survey)

Discussed but not recommended for addition to the 2020 Core Set

Tobacco Use: Screening

and Cessation Intervention

PCPI 0028/0028e

Percentage of patients age 18 and older who were

screened for tobacco use one or more times within 24

months AND who received tobacco cessation

intervention if identified as a tobacco user.

Administrative or EHR

Preventive Care and

Screening: Unhealthy

Alcohol Use: Screening &

Brief Counseling

PCPI 2152

Percentage of patients age 18 years and older who were

screened for unhealthy alcohol use using a systematic

screening method at least once within the last 24 months

AND who received brief counseling if identified as an

unhealthy alcohol user.

EHR or registry

Use of Opioids from

Multiple Providers in

Persons Without Cancer

PQA 2950

Percentage of individuals age 18 and older without

cancer who received prescriptions for opioids from four or

more prescribers AND four or more pharmacies within

less than or equal to 180 days. Lower rates are better for

this measure.

Administrative

B.16

Measure name

Measure

steward NQF # Measure description

Data collection

method

Continuity of

Pharmacotherapy for

Opioid Use Disorder

USC 3175

Percentage of adults 18–64 years of age with

pharmacotherapy for opioid use disorder (OUD) who

have at least 180 days of continuous treatment.

Administrative or EHR

Pharmacotherapy for

Opioid Use Disorder

NCQA Not endorsed

Percentage of new pharmacotherapy treatment episodes

that resulted in 180 or more covered treatment days

among members 16 years of age and older with a

diagnosis of OUD.

Administrative or EHR

Query of Prescription Drug

Monitoring Program

CMS Not endorsed

For at least one Schedule II opioid electronically

prescribed using Certified Electronic Health Records

Technology (CEHRT) during the performance period, the

Merit-based Incentive Payment System eligible clinician

uses data from CEHRT to conduct a query of a

Prescription Drug Monitoring Program for prescription

drug history, except where prohibited and in accordance

with applicable law.

Administrative or EHR

Follow-Up After High-

Intensity Care for

Substance Use Disorder

NCQA Not endorsed

Percentage of acute inpatient hospitalizations, residential

treatment, or detoxification visits for a diagnosis of

substance use disorder that result in a follow-up visit or

service for substance use disorder among individuals 13

years of age and older. Two rates are reported: (1)

percentage of visits or discharges for which the individual

received follow-up for substance use disorder within the

30 days after the visit or discharge, and (2) percentage of

visits or discharges for which the individual received

follow-up for substance use disorder within the 7 days

after the visit or discharge.

Administrative

Dental and Oral Health Services

Discussed but not recommended for addition to the 2020 Core Set

Ambulatory Care Sensitive

Emergency Department

Visits for Dental Caries in

Children

ADA/

DQA

2689

Number of emergency department (ED) visits for caries-

related reasons per 100,000 member months for all

enrolled children. Rates are stratified by age and by ED

visit disposition (visits resulting in an inpatient admission

and those not resulting in an inpatient admission). Lower

rates are better for this measure.

Administrative

B.17

Measure name

Measure

steward NQF # Measure description

Data collection

method

Follow-Up After

Emergency Department

Visits for Dental Caries in

Children

ADA/

DQA

2695

Percentage of caries-related ED visits among children 0

through 20 years in the reporting period for which the

member visited a dentist within (1) 7 days and (2) 30

days of the ED visit.

Administrative

Adults with Diabetes –

Oral Evaluation

ADA/

DQA

Not endorsed

Percentage of enrolled adults with diabetes who received

a comprehensive or periodic oral evaluation or a

comprehensive periodontal evaluation within the

measurement year.

Administrative

Experience of Care

Discussed but not recommended for removal from the 2020 Core Set

Consumer Assessment of

Health Care Providers and

Systems (CAHPS) Health

Plan Survey 5.0H – Child

Version (Medicaid) (CPC-

CH)

NCQA Not endorsed

This measure provides information on parents’

experiences with their child’s health care and gives a

general indication of how well the health care meets their

expectations. Results summarize children’s experiences

through ratings, composites, and individual question

summary rates. The Child Core Set measure includes the

Children with Chronic Conditions Supplemental Items.

Survey

Consumer Assessment of

Health Care Providers and

Systems (CAHPS) Health

Plan Survey 5.0H – Adult

Version (Medicaid) (CPA-

AD)

NCQA Not endorsed

This measure provides information on beneficiaries’

experiences with their health care and gives a general

indication of how well the health care meets the

beneficiaries’ expectations. Results summarize

beneficiaries’ experiences through ratings, composites,

and individual question summary rates.

Survey

Discussed but not recommended for addition to the 2020 Core Set

Child Hospital Consumer

Assessment of Healthcare

Providers and Systems

(CAHPS) Survey

AHRQ 2548

This measure asks parents and guardians of children

under 18 years old to report on their and their child’s

experiences with inpatient hospital care. Results consist

of 39 items organized by overarching groups into 18

composite and single-item measures. The domains

include: Communication with Parent, Communication

with Child, Attention to Safety and Comfort, Hospital

Environment, and Global Rating.

Survey

B.18

Measure name

Measure

steward NQF # Measure description

Data collection

method

Healthy Days Core

Module – Health-Related

Quality of Life

CDC Not endorsed

The four Health-Related Quality of Life Healthy Days

Core Module (HRQOL-4) items ask about self-rated

general health and the number of days when a person

was physically unhealthy, mentally unhealthy, or limited

in usual activities within the previous 30 days. A

summary measure combines physically and mentally

unhealthy days. The module was developed for national

and state surveillance surveys, including the state-based

Behavioral Risk Factor Surveillance System (BRFSS),

the National Health and Nutrition Examination Survey,

and the Medicare Health Outcomes Survey.

Survey

Long-Term Services and Supports (LTSS)

Discussed but not recommended for addition to the 2020 Core Set

Consumer Assessment of

Healthcare Providers and

Systems (CAHPS) Home

and Community Based

Services (HCBS) Survey

CMS 2967

(19 HCBS

CAHPS

measures are

endorsed)

The HCBS CAHPS is a cross-disability survey of the

experience of HCBS beneficiaries receiving LTSS. It is

designed to facilitate comparisons across state Medicaid

HCBS programs that target adults with disabilities,

including frail elderly, individuals with physical disabilities,

persons with developmental or intellectual disabilities,

those with acquired brain injury, and persons with severe

mental illness. The HCBS CAHPS Survey is available for

voluntary use in HCBS programs as part of quality

assurance and improvement activities and public

reporting.

Survey

LTSS: Successful

Transition After Long-

Term Institutional Stay

CMS Not endorsed

Proportion of long-term institutional facility stays among

Medicaid Managed LTSS (MLTSS) plan members age 18

and older, which result in successful transitions to the

community (community residence for 60 or more days).

This measure is reported as an observed rate and a risk-

adjusted rate.

Administrative

B.19

Measure name

Measure

steward NQF # Measure description

Data collection

method

LTSS: Comprehensive

Assessment and Update

CMS Not endorsed

Percentage of Medicaid MLTSS plan members 18 years

of age and older who have documentation of a

comprehensive assessment in a specified time frame that

includes documentation of core elements. The following

rates are reported: (1) assessment of core elements:

MLTSS plan members who had a comprehensive LTSS

assessment with nine core elements documented within

90 days of enrollment (for new members) or annually;

and (2) assessment of supplemental elements: MLTSS

plan members who had a comprehensive LTSS

assessment with nine core elements and at least 12

supplemental elements documented within 90 days of

enrollment (for new members) or annually. In addition,

two rates of required exclusions should be reported: (1)

member could not be contacted for care planning; and (2)

member refused to participate in care planning.

Case management

record review

LTSS: Comprehensive

Care Plan and Update

CMS Not endorsed

Percentage of Medicaid MLTSS plan members 18 years

of age and older who have documentation of a

comprehensive LTSS care plan in a specified time frame

that includes documentation of core elements. The

following rates are reported: (1) care plan with core

elements documented: MLTSS plan members who had a

comprehensive LTSS care plan with nine core elements

documented within 120 days of enrollment (for new

members) or annually; and (2) care plan with

supplemental elements documented: MLTSS plan

members who had a comprehensive LTSS care plan with

nine core elements and at least four supplemental

elements documented within 120 days of enrollment (for

new members) or annually.

Case management

record review

B.20

Measure name

Measure

steward NQF # Measure description

Data collection

method

LTSS: Reassessment/

Care Plan Update After

Inpatient Discharge

CMS Not endorsed

Percentage of discharges from inpatient facilities for

Medicaid MLTSS plan members 18 years of age and

older for whom a reassessment and care plan update

occurred within 30 days of discharge. Two performance

rates are reported: (1) reassessment after inpatient

discharge: percentage of discharges from inpatient

facilities resulting in a LTSS reassessment within 30 days

of discharge; and (2) reassessment and care plan update

after inpatient discharge: percentage of discharges from

inpatient facilities resulting in an LTSS reassessment and

care plan update within 30 days of discharge. In addition,

two rates of required exclusions should be reported: (1)

member could not be contacted for assessment and/or

care planning; and (2) member refused to participate in

assessment and/or care planning.

Case management

record review

Personal Outcome

Measures

CQL Not endorsed

Personal Outcome Measures is a tool designed to ensure

that services and supports are person-centered. In a

Personal Outcome Measures interview, 21 indicators are

used to understand the presence, importance and

achievement of outcomes involving choice, health,

safety, social capital, relationships, rights, goals, dreams,

employment, and more. Measures are organized into five

topic areas: human security, community, relationships,

choices, and goals.

In-depth interview

Other Measures

Discussed but not recommended for addition to the 2020 Core Set

Continuity of Insurance:

Informed Participation

CHOP 3154

This measure assesses the continuity of enrollment of

children in publicly financed insurance programs

(Medicaid and CHIP), as defined by the ratio of enrolled

months to eligible months over an 18-month period

(called an “observation window”). The measure uses a

natural experiment based on the random event of

appendicitis to “inform” the estimate of coverage in a

given state.

Administrative

B.21

Measure name

Measure

steward NQF # Measure description

Data collection

method

Health-Related Social

Needs (HRSN) Screening

CMS Not endorsed

A 10-item screening tool designed to identify patient

needs in 5 domains that can be addressed through

community services (housing instability, food insecurity,

transportation difficulties, utility assistance needs, and

interpersonal safety).

Survey

ECDS data collection method includes data from administrative claims, electronic health records, case management systems, and health information

exchanges/clinical registries.

ADA = American Dental Association; AHRQ = Agency for Healthcare Research and Quality; CDC = Centers for Disease Control and Prevention; CHIP =

Children’s Health Insurance Program; CHOP = Children's Hospital of Philadelphia; CMCS = Centers for Medicaid and CHIP Services; CMS = Centers for Medicare

& Medicaid Services; CQL = Council on Quality and Leadership; DQA = Dental Quality Alliance; ECDS = Electronic Clinical Data System; EHR = Electronic Health

Record; HRSA = Health Resources and Services Administration; NA = Measure is not NQF endorsed; NCQA = National Committee for Quality Assurance; NQF =

National Quality Forum; OPA = Office of Population Affairs; PCPI = Physician Consortium for Performance Improvement; PMCoE = Pediatric Measurement

Center of Excellence; PQA = Pharmacy Quality Alliance; QMETRIC = Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium; TJC =

The Joint Commission; USC = University of Southern California.

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Appendix C

Public Comments on the Draft Report

This page has been left blank for double-sided copying.

C.1

The draft report was available for public review and comment from July 8, 2019 through August

5, 2019 and stakeholders were invited to submit comments via email. A total of 40 public

comments were received. Commenters included state and federal agencies, professional

associations, stakeholder organizations, research firms, and health plans. Mathematica

appreciates the time and effort taken by commenters to prepare and submit their comments on

the draft report.

Exhibit C.1 categorizes the public comments received on the draft report by the following topics:

general comments, measures recommended for removal from or addition to the Core Sets,

measures discussed but not recommended for removal or addition, and gap areas. Many

comments addressed more than one topic. The verbatim public comments are included after the

exhibit, organized in alphabetical order by commenter name (agency/organization or individual

last name).

In summary, public comments were submitted on all seven measures the Workgroup

recommended for removal from the Core Sets, and all five measures recommended for addition.

Comments were also received on 12 measures considered by the Workgroup, but not

recommended for removal from or addition to the 2020 Core Sets.

Exhibit C.1. Summary of Public Comments by Topic and Commenter

Topic Commenter

General Comments

• Adult Vaccine Access Coalition

• American Academy of Pediatrics

• American Association on Health and Disability and the

Lakeshore Foundation

• American Society of Hematology

• Anthem

• Association for Community Affiliated Plans

• California Department of Health Care Services

• Children's Dental Health Project

• Children's Hospital Association

• CVS Health

• Kaiser Permanente

• National Association of State Directors of Developmental

Disability Services

• Novo Nordisk

• Office of Infectious Disease and HIV/AIDS Policy

• YMCA of the USA

Measures Recommended for Removal from the Child Core Set

Children and Adolescents’

Access to Primary Care

Practitioners (CAP-CH)

• Association for Community Affiliated Plans

• California Department of Health Care Services

C.2

Topic Commenter

Weight Assessment and

Counseling for Nutrition and

Physical Activity for

Children/Adolescents – Body

Mass Index Assessment for

Children/Adolescents (WCC-

CH)

• American Academy of Pediatrics

• Association for Community Affiliated Plans

• Christopher Bolling

• California Department of Health Care Services

• Children’s Health Integrated Program in Childhood Obesity

• CVS Health

• Healthy Weight Partnership Inc.

• Kentucky Department for Medicaid Services

• Michael & Susan Dell Center for Healthy Living

• National Association of Community Health Centers

• New Balance Foundation for Obesity Prevention Center,

Boston Children’s Hospital

• Novo Nordisk

• Obesity Care Advocacy Network

• Redstone Center, Milken Institute School of Public Health

• Trust For America’s Health

• University of Texas School of Public Health

• YMCA of the USA

Pediatric Central Line-

Associated Bloodstream

Infections (CLABSI-CH)

• Association for Community Affiliated Plans

• California Department of Health Care Services

Use of Multiple Concurrent

Antipsychotics in Children

and Adolescents (APC-CH)

• Anthem

• Association for Community Affiliated Plans

• California Department of Health Care Services

Measures Recommended for Removal from the Adult Core Set

Adult Body Mass Index

Assessment (ABA-AD)

• Association for Community Affiliated Plans

• Christopher Bolling

• California Department of Health Care Services

• Kentucky Department for Medicaid Services

• Novo Nordisk

• Obesity Care Advocacy Network

• Redstone Center, Milken Institute School of Public Health

• Trust For America’s Health

• University of Texas School of Public Health

• YMCA of the USA

Comprehensive Diabetes

Care: Hemoglobin A1c

(HbA1c) Testing (HA1C-AD)

• Association for Community Affiliated Plans

• California Department of Health Care Services

• District of Columbia Department of Health Care Finance

• Novo Nordisk

• YMCA of the USA

Annual Monitoring for

Patients on Persistent

Medications (MPM-AD)

• Association for Community Affiliated Plans

• California Department of Health Care Services

C.3

Topic Commenter

Measures Recommended for Addition to the 2020 Core Sets

Appropriate Antibiotic

Prophylaxis for Children with

Sickle Cell Anemia

• American Board of Pediatrics

• American Society of Hematology

• Anthem

• Association for Community Affiliated Plans

• California Department of Health Care Services

• Children's Hospital Association

• CVS Health

• District of Columbia Department of Health Care Finance

• Kaiser Permanente

• Kentucky Department for Medicaid Services

Metabolic Monitoring for

Children and Adolescents on

Antipsychotics

• Anthem

• Association for Community Affiliated Plans

• California Department of Health Care Services

• Kaiser Permanente

Use of Pharmacotherapy for

Opioid Use Disorder

• Anthem

• Association for Community Affiliated Plans

• California Department of Health Care Services

• CVS Health

• District of Columbia Department of Health Care Finance

• Kaiser Permanente

National Core Indicators

• American Association on Health and Disability and the

Lakeshore Foundation

• Anthem

• Association for Community Affiliated Plans

• California Department of Health Care Services

• Connecticut Department of Developmental Services

• District of Columbia Department of Health Care Finance

• Human Services Research Institute

• Indiana Division of Disability and Rehabilitative Services

• Kaiser Permanente

• Kentucky Department for Medicaid Services

• Maryland Department of Health

• Minnesota Department of Human Services

• Missouri Division of Developmental Disabilities

• National Association of State Directors of Developmental

Disability Services

National Core Indicators for

Aging and Disabilities

• American Association on Health and Disability and the

Lakeshore Foundation

• Anthem

• Association for Community Affiliated Plans

• California Department of Health Care Services

• District of Columbia Department of Health Care Finance

• Human Services Research Institute

• Kaiser Permanente

• Kentucky Department for Medicaid Services

• Minnesota Department of Human Services

C.4

Topic Commenter

Measures Considered and Not Recommended for Addition by Domain

Primary Care Access and

Preventive Care Domain

• Adult Vaccine Access Coalition

• Biotechnology Innovation Organization

• Connecticut Children’s Office for Community Child Health/Help

Me Grow National Center

• Kaiser Permanente Washington Health Research Institute

Maternal and Perinatal Health

Domain

• Connecticut Children’s Office for Community Child Health/Help

Me Grow National Center

Care of Acute and Chronic

Conditions Domain

• American Board of Pediatrics

• Children's Hospital Association

• CVS Health

Behavioral Health Care

Domain

• CVS Health

Dental and Oral Health

Services Domain

• American Academy of Pediatrics

• Children's Dental Health Project

• Kaiser Permanente

Long Term Services and

Supports Domain

• Aging and Disability Policy and Leadership Consulting, LLC

• American Association on Health and Disability and the

Lakeshore Foundation

• Anthem

• Human Services Research Institute

• Indiana Division of Disability and Rehabilitative Services

• Maryland Department of Health

• Minnesota Department of Human Services (Missouri Division of

Developmental Disabilities

Gap Areas

• Adult Vaccine Access Coalition

• American Association on Health and Disability and the

Lakeshore Foundation

• Biotechnology Innovation Organization

• Children's Dental Health Project

• Connecticut Children’s Office for Community Child Health/Help

Me Grow National Center

• Allison LaRussa

C.5

PUBLIC COMMENTS LISTED ALPHABETICALLY BY

AGENCY/ORGANIZATION NAME OR INDIVIDUAL

COMMENTER’S LAST NAME

Adult Vaccine Access Coalition (Abby Bownas)

The Adult Vaccine Access Coalition (AVAC) appreciates the opportunity to comment on

Mathematica’s Summary of a Multi-stakeholder Review of the 2020 Child and Adult Core Sets.

We appreciate the Workgroup’s interest in strengthening and improving the Medicaid Child and

Adult Health Care Quality Core Sets for 2020, and their recognition of the importance of quality

measures to improve the health of individuals and entire communities.

AVAC encourages the Workgroup take a focused, concerted approach to adult immunizations

as a means of improving population health as well as the overall health of Medicaid patients.

We hope that as part of your final recommendations, the Workgroup will reconsider adoption of

two recent HEDIS immunization measures.

• Adult Immunization Status (AIS). Add the new Adult Immunization Status (AIS) measure, to

replace the current adult influenza vaccine measure based on Consumer Assessment of

Healthcare Providers and Systems (CAHPS) surveys. The new AIS measure is a composite

of the age-recommended vaccines for adults, including influenza vaccine.

• Prenatal Immunization Status. Add the new Prenatal Immunization Status, which measures

prenatal immunizations of Tdap and influenza. Retain the other two current immunization

measures: Childhood immunization status (CIS) and Immunization of Adolescents (IMA).

AVAC consists of over 50 organizational leaders in health and public health that are committed

to addressing the range of barriers to adult immunization and to raising awareness of the

importance of adult immunization. AVAC works towards common legislative and regulatory

solutions that will strengthen and enhance access to adult immunization across the health care

system. Our priorities and objectives are driven by a consensus process with the goal of

enabling the range of stakeholders to have a voice in the effort to improve access and utilization

of adult immunizations.

Potential Gap Areas for Future Core Set Measures

We appreciate the draft Workgroup report noted gaps in terms of immunization quality

measures, particularly with regard to prenatal and adult populations. Significant racial and ethnic

disparities currently exist in adult immunization

coverage rates and the failure to improve these

rates among the Medicaid population only exacerbates these disparities. Opportunities to

assess the immunization status of Medicaid beneficiaries, particularly pregnant women and

medically vulnerable adults with chronic conditions such as diabetes and heart disease, should

be done by the range of clinicians who care for them, including primary care and specialty

providers. Taking advantage of each and every patient encounter to facilitate counseling and

education on vaccines, based on their age and health status, and to offer a strong provider

recommendation have been found to improve the likelihood of a patient being immunized.

C.6

Published literature indicates that integrating immunization assessment and additional providers

offering these critical preventive services will result in greater opportunities for immunization.

The National Vaccine Advisory Committee’s (NVAC) Adult Immunization Standards call for all

providers caring for adult patients to assess, recommend, vaccinate or refer, and document

vaccinations. Immunization quality measures are a crucial tool for health care quality

improvement and have demonstrated effectiveness in improving immunization coverage across

adult populations. Quality measures, such as the adult immunization status measure and the

prenatal immunization status measure can help to fill gaps while eliminating disparities around

adult immunization moving forward.

Adult Immunization Status Measure

AVAC recommends that the Workgroup replace the current adult influenza vaccine measure

based on Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. The

new AIS measure is a composite of several age-recommended vaccines for adults, including

the influenza vaccine. An adult immunization composite measure would provide a sound,

reliable and comprehensive means to assess the receipt of routine adult vaccinations

recommended by the Advisory Committee on Immunization Practices (ACIP). The Adult

Immunization Status (AIS) measure should be adopted as a final recommendation of the

Workgroup because it includes more vaccines than the current immunization measure (FVA-

AD) and would help states monitor recommended adult immunization use beyond influenza.

Many adult patients are not being assessed and offered important ACIP-recommended

vaccines, resulting in poor adult immunization coverage rates nationally.

Despite the clear harm

from influenza, as witnessed during the 2017-2018 influenza season, immunization coverage

rates continue to lag behind Healthy People 2020 goals. While the benefits of pneumococcal

vaccination of adults with certain chronic high-risk conditions are well documented, only about

20% of these persons are vaccinated. Adults over the age of 65 are especially vulnerable to

complications from vaccine preventable diseases and thus are recommended for vaccinations

including influenza, pneumococcal, and zoster. Unfortunately, even in this most vulnerable

population, vaccination coverage rates are below national goals.

In the Value and Imperative of Quality Measures for Adult Vaccines, renowned vaccine experts

explain how quality measures that capture and create incentives for appropriate adult

vaccinations can prevent illness and death, reduce caregiving demands, avoid unnecessary

healthcare spending, and set the foundation for healthy aging.

There is evidence that a

composite measure of the adult immunization schedule, such as those demonstrated by the

Northwest Tribal Epidemiology Center and by the National Nursing Home Quality Care

Collaborative, can improve patient health outcomes

. Adoption of an AIS measure would put

vaccination coverage rates into a larger context and encourage a more systematic approach for

all vaccines. Additionally, the HHS Office of Infectious Disease and HIV/AIDS Policy (OIDP) and

the Centers for Disease Control and Prevention (CDC) in collaboration with the National Adult

Immunization and Influenza Summit Quality Working group were instrumental in spearheading

the development and testing of a the AIS measure, along with the composite measure for

prenatal immunization, which has been adopted as part of HEDIS. We understand that the

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Workgroup expressed concerns with states’ ability to accurately and reliably report the

immunization measures. The measures draw from Electronic Clinical Data Systems (ECDS),

which include immunization information systems (IIS), case management registries, claims, and

electronic health records (EHRs). We understand that while state Medicaid and CHIP programs

can access member claims, encounters, and the corresponding state/local Immunization IIS, it

may be more of a challenge for many state Medicaid agencies to capture EHR data. Therefore,

states could choose to assess different models of data capture, such as encouraging providers

to report to a community, regional or state-based health information exchange, in order to build

capacity for measures that rely on electronic clinical information. The National Committee for

Quality Assurance (NCQA) tested both measures in Medicaid and commercial health plans,

concluding that while the specifications are new and innovative, they are feasible to implement.

In addition, workgroup members representing state Medicaid programs expressed their

commitment to establishing the infrastructure by which to report these new data sources.

Because reporting measures within the Adult Core Set is currently voluntary, inclusion of these

new immunization measures would signal prioritization of this critical public health gap, while

allowing states to work on this new method of data collection and measure reporting. AVAC

supports the Workgroup member recommendation that CMCS consider an affinity group or

grant opportunity to help drive state coordination between Medicaid and public health registries,

particularly immunization registries. Immunization information systems, or registries are an

essential tool in managing immunization record data that enables providers to have accurate

information regarding a Medicaid beneficiary’s immunization status.

Prenatal Immunization Status Measure

AVAC urges the Workgroup to reconsider adoption of the prenatal immunization status

measure, which includes Tdap and influenza for 2020. Maternal and perinatal health has been

identified in prior reviews as an area to strengthen in the quality measure sets.

Like the AIS, the Prenatal Immunization Status measure will help to address substantial

disparities in prenatal immunization rates. Immunizing mothers during their third trimester

protects 9 in 10 babies from pertussis infections serious enough to need treatment in a

hospital.

Currently, prenatal immunization levels are lower among Medicaid members

compared to privately insured women. Getting a flu shot reduces a pregnant woman's risk of

hospitalization by 40% and helps protect the newborn before he/she is old enough to be

vaccinated. We appreciate that the Workgroup members acknowledged the importance of the

prenatal immunization status measure and its strong connection to improved health outcomes

for young infants. However, we respectfully disagree with the decision not to adopt the measure

because of data collection concerns.

The development and implementation of two new HEDIS 2019 measures—and adult

immunization composite measure comprising influenza, pneumococcal, zoster, and Tdap

vaccines and a prenatal (maternal) immunization measure comprising Tdap and influenza

vaccines—illustrates the recognition of the importance of adult immunization in protecting health

and the preventing disease in these medically vulnerable groups.

Adoption of these two quality

measures would provide useful and actionable results for state Medicaid and CHIP programs,

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especially if they publicly post results and require reporting by Medicaid managed care plans.

Such performance assessment and feedback can drive quality improvement efforts to raise

immunization coverage rates. At the same time, the addition of these two new measures to the

Adult and Child Core set is critical to improving the health of adult and prenatal populations.

Again, thank you for the opportunity to share our perspective on this draft report. AVAC looks

forward to working with Mathematica on this important endeavor. Please contact an AVAC

Coalition Manager at (202) 540-1070 or in[email protected] if you wish to further

discuss our comments. To learn more about the work of AVAC visit www.adultvaccinesnow.org.

Citations

Williams, W.W. et al. MMWR Surveillance Summary 2017;66(11):1–28.

Quilici et al. “Role of vaccination in economic growth.” J Mark Access Health Policy; (2015)

3:10.3402/jmahp.v3.27044.

National Vaccine Advisory Committee. 2014. Public Health Rep. 2014 Mar-Apr; 129(2): 115–

123.

https://dev-adultvaccinesnow.pantheonsite.io/wp-content/uploads/2016/07/AVN-White-Paper-

FINAL.pdf.

https://www.hhs.gov/sites/default/files/tab_10.05_weiser_adult_iz_composite-measures.pdf.

https://www.cdc.gov/pertussis/pregnant/mom/vacc-effectiveness.html.

https://www.ncqa.org/news/ncqa-updates-quality-measures-for-hedis-2019/.

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Aging and Disability Policy and Leadership Consulting, LLC (Lowell Arye)

I am writing to provide comments on the 2020 Core Set Review. As a member of the

Workgroup, I want to thank you for all the work you did in facilitating the meetings (both face to

face and the webinars). I also believe that the draft report does a good job in providing a

synopsis of our discussions and our recommendations.

My only comment is that I believe there needs to be more specificity included in some of the

reasons for the additions/deletions which were recommended. Specifically, in the area of Long

Term Services and Supports (LTSS), I believe that it would be useful to explain that

approximately 32% of all Medicaid expenditures are for LTSS and that it the workgroup found it

important to include measurements in the Core Set for almost a third of all Medicaid

expenditures. Similar information could be useful for the other additions as well.

I believe that inclusion of this information provides the case to CMS for inclusion of these

measurements in the Core Set. Thank you for all of your work. I look forward to the final report.

C.10

American Academy of Pediatrics (Kyle E Yasuda)

Thank you for the opportunity to review and provide comment on the Recommendations for

Improving the Core Sets of Health Care Quality Measures for Medicaid and CHIP Summary of a

Multistakeholder Review of the 2020 Child and Adult Core Sets. The American Academy of

Pediatrics (AAP) is an organization of 67,000 pediatricians, pediatric medical sub-specialists,

and pediatrics surgical specialists dedicated to the health, safety, and wellbeing of infants,

children, adolescents, and young adults. We have a long history of supporting our members to

ensure that “every child gets the right care every time” through a range of programs, activities,

and resources.

The development and implementation of national pediatric measures has moved considerably

slower than those of adults due to lack of evidence, risk adjustment, unreliable data sources,

and small patient populations for chronic pediatric conditions. Despite these challenges, the

AAP has remained a strong advocate supporting the harmonization of national quality

measurement efforts that promote child health and can be used for value-based payment. The

AAP promotes quality measures that: 1) Have a meaningful impact on child health and promote

the health of every child, 2) Utilize an evidence based or evidence informed approach when

determining impact on child health and development, 3) Are feasible for pediatricians and those

who care for children to collect and, 4) Reflect the diversity of pediatric care by covering the

broad range and complexity of pediatrics within a social determinants context.

Overall, the Academy agrees with the goals set forth by the workgroup to focus on measures

that are actionable, aligned, and appropriate for state-level reporting to drive improvement in the

quality of care and health outcomes. We strongly agree with the need to address gaps in the

core set pertaining to the social determinants of health. We also applaud Mathematica’s

transparency around the criteria for the recommended removal and additions from the CHIPRA

core set; as they are mostly in alignment with the Academy’s criteria for impacting child health.

We do however offer several suggestions for improvement on the process for assessing

measures as well as specific comments on several measure removals.

Regarding improvements on the process of measure assessment, we encourage Mathematica

to examine measures within and across domains for children. Children differ from adults and

models for pediatric quality measurement should take this diversity into account. Unique

differences between children and adults are often described in the literature include

development, dependency, differential epidemiology, demographics, and dollars. Children have

an upward developmental trajectory, with needs and abilities changing over time. Effectively

measuring children’s health requires more of a systems approach and examination of measures

across domain areas with further consideration on how these measures interact as a core set.

The types of care (prevention/wellness, acute care, mental/behavioral health), sites of care,

(inpatient, outpatient, school-based), healthy behaviors, overuse and appropriate treatment,

family and community engagement should all be considered.

The Academy is concerned about the removal of measures pertaining to oral health and body

mass index (BMI). Dental caries is the most common chronic condition of childhood –

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disproportionally affecting children in Medicaid/CHIP and has implications on pain, Emergency

Department use, school (individual and group success), and long-term systemic health. The oral

health measures were removed without replacement, speaking against the 4th characteristic

(new or alternate measure) as mentioned in Exhibit ES.1. The AAP recommends that the oral

health measures should remain on the table for consideration in future sets due to the

importance of children’s oral health to overall health.

We also urge you to reconsider the removal of the Weight Assessment and Counseling in

Children. While we understand that the high performance of this measure is the reason for

removal, it is because of the current requirement, pediatricians across the country now check

BMI at every visit. Furthermore, children with disabilities have many competing demands during

their visits, and healthy weight counseling often gets overlooked. With decreased emphasis on

BMI measurement, children and teens that are just starting to increase their BMI and may miss

the opportunity for early intervention.

The AAP recognizes the effort Mathematica has put into the review process and the

development of the report. We applaud you for your commitment to improving health outcomes.

Thank you again for considering comments from the Academy. Please feel free to contact

Vanessa Shorte, Senior Director of Quality, at v[email protected] should you have questions.

C.12

American Association on Health and Disability and the Lakeshore

Foundation (Clarke Ross)

The American Association on Health and Disability and the Lakeshore Foundation appreciate

the opportunity to provide comments.

The American Association on Health and Disability (AAHD) (www.aahd.us) is a national non-

profit organization of public health professionals, both practitioners and academics, with a

primary concern for persons with disabilities. The AAHD mission is to advance health promotion

and wellness initiatives for persons with disabilities.

The Lakeshore Foundation (www.lakeshore.org) mission is to enable people with physical

disability and chronic health conditions to lead healthy, active, and independent lifestyles

through physical activity, sport, recreation and research. Lakeshore is a U.S. Olympic and

Paralympic Training Site; the UAB/Lakeshore Research Collaborative is a world-class research

program in physical activity, health promotion and disability linking Lakeshore’s programs with

the University of Alabama, Birmingham’s research expertise.

Overview

As a member of various related National Quality Forum committees since 2012 and as an

observer of this CMS-Mathematica Core Set Workgroup considerations, we find the report an

accurate and thoughtful description and summary of the workgroup’s discussions and decisions.

Thank you.

We reinforce the page 28 (pages when viewing the document from a web browser) Theme:

The Workgroup focuses on “a holistic approach to measuring the quality of care provided to

diverse populations and subpopulations enrolled in Medicaid and CHIP.” Numerous NQF

meetings and reports have emphasized the importance of the populations and subpopulations

when discussing quality and the Medicaid program. Thank you.

In discussing the Theme and overall approach, it might be helpful to remind the Medicaid and

CHIP audiences of the National Quality Strategy “Triple Aim” as a reference guide to the

nation’s approach to quality measurement in health and related services and supports. The

Triple Aim priorities are: (1) Improving the Patient Experience of Care; (2) Improving the health

of the population; and (3) Reducing the per capita cost of health care.

Long-Term Services and Supports: Overview

We appreciate the Appendix, page 54 (pages when viewing the document from a web browser)

concluding observation: “Workgroup members noted the importance of adding LTSS measures,

as this population comprises a large and growing share of the Medicaid beneficiaries and

Medicaid expenditures and existing measures do note capture the unique needs and

experiences of this populations.”

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Further, the Appendix, page 55 states: Workgroup members recognize that “it is important to

find a way to better understand the experiences of people receiving LTSS.” And further on page

55: “In light of the significant resources that states invest in LTSS, it is important to provide

feedback to the Medicaid program.”

We recommend that these observations be moved from the Appendix discussion of particular

LTSS proposed measures to the actual text of the report.

And, we concur and support the comments submitted on the draft report for public comment by

Workgroup member Lowell Arye: “There needs to be more specificity included in some of the

reasons for the additions/deletions which were recommended. Specifically, in the area of Long

Term Services and Supports (LTSS), ….it would be useful to explain that approximately 32% of

all Medicaid expenditures are for LTSS and that the workgroup found it important to include

measurements in the Core Set for almost a third of all Medicaid expenditures. Similar

information could be useful for the other additions as well…..Inclusion of this information

provides the case to CMS for inclusion of these measurements in the Core Set.”

We appreciate the page 28 Theme observation that Medicaid wraparound services are not

being captured by the current core set.

Long-Term Services and Supports (LTSS): National Core Indicators and National Core

Indicators-Aging and Disability

We are delighted that the Workgroup voted to recommend to CMS the addition to the 2020 Core

Measure Set: both NCI and NCI-AD (pages 9, 21, 26, 27) (pages when viewing the document

from a web browser). We reinforce the need and importance of such recommendations.

Long Term Services and Supports (LTSS): CAHPS HCBS Experience Survey and Personal

Outcome Measures

The draft report for public comment Appendix discussion of CAHPS HCBS and POM is accurate

and helpful (pages 54, 55, 63, and 65). Missing from the report is the recognition that the

CAHPS HCBS failed recommendation for inclusion into the 2020 core set by one vote. This

recognition would enhance the significance of this measure compared with the many other

measures not endorsed for 2020 inclusion.

The Appendix discussion for both CAHPS HCBS and POM emphasize Workgroup concern with

the high-cost and time intensiveness of collecting data through these mechanisms. This is an

accurate reporting. We suggest that the report reference the NQF HCBS final report; home and

community-based services and supports are person-centered and highly individualized, a

reason for time intensive individual engagements.

Gaps

Thank you for the very helpful identification of measure gaps on page 29. To AAHD and the

Lakeshore Foundation, we particularly reinforce: individuals of all ages with disabilities including

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living and participating in the community; LTSS including rebalancing; behavioral health

integration with primary care and physical health; care transitions; and addressing social

determinants of health.

Thank you for the opportunity to comment. If you have any questions please contact Clarke

Ross at [email protected].

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American Board of Pediatrics (David Nichols)

The American Board of Pediatrics strongly supports the inclusion of the two core set measures

related to sickle cell disease:

1. Appropriate Antibiotic Prophylaxis for Children with Sickle Cell Anemia (NQF #3166)

2. Transcranial Doppler Ultrasonography Screening for Children with Sickle Cell Anemia (NQF

#2797)

The percentage of children with sickle cell disease who receive recommended antibiotic

prophylaxis and transcranial doppler screening is persistently low and in some cases, even

falling. The inclusion of these measures would have an immediate and dramatic impact of

focusing pediatricians on the importance of these care elements. This simple step would go a

long way in reducing a glaring health care disparity in the United States. Other chronic illnesses

of childhood (e.g., cystic fibrosis, inflammatory bowel disease) have seen dramatic

improvements in care, but sickle cell disease has not, in part because of the absence of

validated measures.

We urge the adoption of these core set measures in the strongest possible terms.

C.16

American Society of Hematology (Emily Cahill)

The American Society of Hematology (ASH) strongly supports the draft report

Recommendations for Improving the Core Sets of Health Care Quality Measures for Medicaid

and Chip: Summary of a Multistakeholder Review of the 2020 Child and Adult Core Sets,

including the inclusion of the following core set measure related to sickle cell disease:

Appropriate Antibiotic Prophylaxis for Children with Sickle Cell Anemia (NQF #3166)

With this inclusion, ASH commends the Workgroup for formally recognizing the marked quality

gap in clinical care provided for children with sickle cell disease. The antibiotic prophylaxis

measure, characterized as a continuity of care measure that should be universally applied and

is captured by claims data, is an appropriate addition to the 2020 Child Core Set. ASH

appreciates the opportunity to comment on this important work and to highlight this great

opportunity to drive improvement in the clinical care of children with sickle cell disease.

ASH is committed to addressing the burden of sickle cell disease (SCD) and is in the midst of a

multifaceted initiative to improve outcomes for individuals with the disease both in the United

States and globally. ASH is leading a number of activities to ensure that individuals with SCD

have access to high quality of care, including the development of new clinical practice

guidelines on the management of acute and chronic complications of SCD, and expanded SCD-

focused education and training.

Please let me know if you have any questions or would like to discuss further.

C.17

Anthem (Anthony Mader)

Anthem, Inc. (Anthem) appreciates this opportunity to comment on Mathematica’s draft report

“Recommendations for Improving the Core Sets of Health Care Quality Measures for Medicaid

and CHIP,” released in July 2019.

We appreciate Mathematica’s convening of the 2020 Child and Adult Core Set Annual Review

Stakeholder Workgroup (Workgroup) and the Workgroup’s thoughtful assessment of the

Centers for Medicare & Medicaid Services’ (CMS) Medicaid and CHIP Child and Adult Core

Sets (Core Sets) of healthcare quality measures. Anthem largely supports the Workgroup’s

recommended changes to the Core Sets for 2020 based on its review of the 2019 Core Sets.

However, we ask that the Workgroup consider the comments provided below as the Workgroup

finalizes its recommendations.

Detailed Comments

Workgroup Recommendations of Measures to Remove from the 2020 Core Sets

Anthem generally agrees with the Workgroup’s recommendations to remove certain measures

from the 2020 Core Set. In cases where the measure is due to be retired by its steward, it is

logical to remove it from the Core Set. However, we recommend the Use of Multiple Concurrent

Antipsychotics in Children and Adolescents (ACP-CH) be retained in the Child Core Set. The

Workgroup framed this measure as potentially “topped out,” but we believe there is still both

value and room for improvement, particularly for the Medicaid population, including children and

youth supported by the child welfare system.

The Workgroup recommended that the measure be replaced by Metabolic Monitoring for

Children and Adolescents on Antipsychotics. While we recommend that Use of Multiple

Concurrent Antipsychotics in Children and Adolescents (ACP-CH) be retained, we also support

adding this new measure, as both would add value to the Child Core Set.

Workgroup Recommendations of Measures to Add to the 2020 Core Sets

The Workgroup proposes to add two National Core Indicators (NCI) measure sets. We support

the concept of adding more quality measures pertaining to individuals requiring Long-Term

Services and Supports (LTSS). However, we are concerned that these survey measures were

not designed for use as health plan quality measures. The measure specifications are not in the

public domain and they would rely on time-intensive in-person interviews. If the individuals

conducting the in-person interviews have not had adequate training in interview techniques, the

validity of these surveys may be questionable. In addition, the sample size is small, so although

these interviews can provide valuable insights into the experiences of individuals, the

information may be limited. There are more appropriate ways for CMS to encourage states’ use

of the NCI and NCI-Aging and Disabilities (NCI-AD) instruments, and we recommend CMS

consult with Human Services Research Institute (HSRI) about the potential difficulties of

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individual health plans using these measure sets before proceeding with adding them to the

Core Set(s).

Understanding that it may be too late in the process to recommend alternative measures for

2020, we instead recommend considering alternative measures for 2021 that would still achieve

the goal of measuring quality for the LTSS Medicaid population, while also being more broadly

impactful. For example, earlier this year, CMS, with help from Mathematica and the National

Committee for Quality Assurance (NCQA), released technical specifications for measures being

developed specifically for individuals accessing LTSS through Managed Care Organizations

(MCOs), some of which are aligned with Healthcare Effectiveness Data and Information Set

(HEDIS) measures. Data collection for these measures can be collected through case

management record review or administratively, making them likely less burdensome as well.

We are also concerned with the addition of the Appropriate Antibiotic Prophylaxis for Children

with Sickle Cell Anemia and the Use of Pharmacotherapy for Opioid Use Disorder measures,

specific to states that carve-out pharmacy from the medical benefit. Health plans operating in

carve-out markets have little opportunity to improve quality on these measures because we do

not directly manage the benefit. The ability for MCOs to provide whole-person care for its

members by fully integrating medical and pharmacy care is extremely helpful in maximizing the

quality of care and services for our members. Anthem is invested in whole-person care to

achieve optimal health outcomes, and a carve-out limits our ability to holistically coordinate and

manage care for our members.

We welcome the opportunity to discuss our recommendations to ensure the delivery of robust

benefits and access to quality care and services via the Medicaid and CHIP programs. Should

you have any questions or wish to discuss our comments further, please contact Lisa Watkins at

(202) 508-7889, or [email protected].

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Association for Community Affiliated Plans (Margaret A Murray)

The Association for Community Affiliated Plans (ACAP) appreciates the opportunity to submit

comments on proposed changes to Child and Adult Core Measures. ACAP is an association of

66 nonprofit and community-based Safety Net Health Plans located in 29 states. Collectively,

ACAP health plans provide coverage to 20 million individuals enrolled in Medicaid, the

Children’s Health Insurance Program (CHIP), Medicare Special Needs Plans for dually-eligible

individuals, and Qualified Health Plans (QHPs) serving the health insurance Marketplaces.

ACAP plans are members of their communities, partnering with states to improve the health and

well-being of their members who rely upon Medicaid and CHIP as well as other publicly-

supported programs. We first will provide some general comments and then respond to specific

measure recommendations below.

General Comments

Overall Criteria: ACAP member plans agree with overarching criteria for removing measures in

which performance is going well and focusing on areas of known needed improvement. We also

support the use of measures where they are populated via administrative data

(encounters/claims) versus manual file review. Finally, we support selecting measures that are

impactable and would encourage the use of strategic workgroups that include the provider

community to be engaged with improving outcomes for select measures that remain challenging

year-over-year.

Outcomes vs Process Measures: In general, ACAP understands and appreciates the interest in

moving from process measures to outcomes measures. However, we know that peer-reviewed

publications are providing increasing evidence that there are confounding variables (beyond the

scope of influence by plans and providers) that impact outcomes measures more than they

impact process measures. These confounding variables are issues related to social

determinants of health (SDoHs). While Safety Net Health Plans (and other health plans) are

moving into the realm of addressing SDoHs, it is uncharted territory. Until this new evidence

matures, and interventions that effectively impact SDoHs are funded by state and federal

sources, we are concerned that replacing all process measures with outcomes measures does

not sufficiently recognize those SDoH-related confounding variables that may impact outcomes

rates due to issues not in control of health plans.

Proposed Measures for Removal

Child and Adolescents’ Access to Primary Care Practitioners (CAP-CH)

Support.

Weight Assessment and Counseling for Nutrition and Physical Activity for

Children/Adolescents— Body Mass Index Assessment for Children/Adolescents (WCC-CH)

Support with Concern.

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While ACAP supports the removal of this measure in general based on many of its limitations

noted in the report, we remain concerned about the absence of a replacement measure that

addresses obesity. We understand that simple measurement without a planned, evidence-

based intervention may seem less impactful, but obesity is the major health problem in the U.S.

and is increasing. Measuring BMI signals to primary care providers the importance of the issue

and marks a place to start. As noted in the report, a federal liaison voicing support remarked

that “…there is evidence to support BMI screening in the primary care setting and that BMI

screening is part of American Academy of Pediatrics and USPSTF recommendations for both

children and adults.” Indeed, this report, as evidenced by Exhibit 8, notes that “Obesity” is a

potential gap area for future core set measures.

Pediatric Central Line–Associated Bloodstream Infections (CLABSI-CH)

Support.

Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC-CH)