How Medicaid Agencies Can Leverage Multi-Payer Aligned Measure Sets
Grace Flaherty and Matt Reynolds, Bailit Health
This expert perspective reviews how Medicaid programs in Connecticut, Massachusetts and Rhode Island have engaged with commercial payers, providers, patients, advocates and other parties to create and adhere to multi-payer aligned measure sets.[i]
What Is an Aligned Measure Set?
Quality incentives are a common feature of health plan provider contracts. Plans provide financial incentives to providers for meeting targets or demonstrating improvement on a set of quality measures as a way of encouraging high quality healthcare. However, it creates several problems when plans use distinct measure sets. First, providers experience greater administrative burden in reporting performance for varying quality measure sets. In addition, it is much harder for providers to focus quality improvement efforts when each insurer is indicating its non-aligned priorities through contractual measures. To reduce reporting burden and focus providers’ quality improvement efforts, states have convened multi-stakeholder work groups (which include state Medicaid agency representation) to develop common sets of quality measures, often referred to as “aligned measure sets,” that payers agree to adopt for use in provider contracts. The specific agency responsible for convening these stakeholder bodies can vary from state to state, depending on the state’s healthcare governance structure and priorities.
Connecticut, Massachusetts, and Rhode Island are three states that have created and maintain aligned measure sets. The states’ Medicaid agencies have chosen to voluntarily align with the measure sets.
Connecticut’s aligned measure set was first established in 2016 as part of the state’s Centers for Medicare & Medicaid Services (CMS) State Innovation Model (SIM) program. The aligned measure set is maintained by the Connecticut Office of Health Strategy (OHS) through its Quality Council, which includes healthcare providers, health insurance experts, patient advocates, consumer representatives, and state agencies. The agency that houses Connecticut’s state Medicaid agency, the Department of Social Services (DSS), is represented on the Quality Council and has been working towards alignment with the aligned measure set.
In 2017, the Massachusetts Executive Office of Health and Human Services, Health Policy Commission, and Center for Health Information and Analysis first convened the Quality Measure Alignment Taskforce (“Taskforce”), which consists of representatives from provider organizations, health plans, academic experts, consumer advocates, and state agencies. The Taskforce developed the first iteration of its aligned measure set for use in 2019 contracts. Massachusetts’ aligned measure set focuses on ambulatory measures for voluntary adoption by private and public payers and by providers in global budget-based risk [i.e., accountable care organization (ACO)] contracts. Representatives from Massachusetts’ state Medicaid agency, MassHealth, have been engaged participants on the Taskforce since its inception and, while the Taskforce has permitted MassHealth to use several measures that deviate from the aligned measure set to meet Medicaid-specific program needs to address the populations served, MassHealth has otherwise exemplified stellar adherence to Massachusetts’ aligned measure set.
Rhode Island developed its Office of the Health Insurance Commissioner (OHIC) aligned measure sets for use in commercial provider contracts in 2015. The aligned measure sets were developed as a CMS SIM grant activity and are now insurer regulatory requirements in the OHIC’s Affordability Standards. As of 2023, Rhode Island maintains six aligned measure sets for the following contracts: (1) ACO, (2) acute care hospital, (3) behavioral health hospital, (4) maternity, (5) outpatient behavioral health and (6) primary care. OHIC maintains and updates its aligned measure sets with annual input from its Measure Alignment Work Group, which includes payers, providers, consumers and representation from the Rhode Island Executive Office of Health and Human Services (EOHHS), the state’s Medicaid agency. Rhode Island EOHHS has committed to voluntary alignment with the aligned measure sets through its Accountable Entity Common Measure Slate (measures that apply to Rhode Island Medicaid accountable care organizations).
How Medicaid Agencies Can Benefit From Participating in Aligned Measure Set Efforts
By engaging with other payers to create an aligned measure set, state Medicaid agencies can:
- Learn From Stakeholders: Measure alignment work groups provide an opportunity for Medicaid agencies to gain valuable insight from other stakeholders about priority health issues, measure implementation challenges, opportunities and barriers to improvement in clinical care, and innovations in quality measurement. Medicaid staff can learn from providers about measure flaws that a Medicaid agency may be unlikely to uncover on its own. Medicaid staff also benefit from hearing additional perspectives on care delivery and quality measures from the various stakeholder types represented on the work groups, though it is also helpful to hear different perspectives within the same stakeholder group (e.g., primary care providers versus behavioral health providers).
- Support Value-Based Program Development: Aligned measure sets may serve as a useful reference point for Medicaid value-based payment programs. There are numerous quality measures in existence and Medicaid agencies may find it challenging to select a discrete set for a value-based program. An aligned measure set is a source for pre-vetted measures with which providers may already be familiar. For example, Connecticut DSS used the state’s aligned measure set as the basis for selecting quality measures when designing a new maternity episode-based payment program.
- Advance Medicaid Agency Priorities: Measure alignment work groups provide an opportunity for Medicaid agencies to voice and advocate for their quality improvement priorities. If Medicaid’s priority measures are incorporated into a state aligned measure set, they may be adopted more broadly across payers, increasing the likelihood that providers will invest in improving performance on these measures.
- Facilitate Provider Participation in Medicaid: Aligning quality measures across commercial and Medicaid contracts can lessen provider concerns about the potential for added administrative burden associated with participating in a state’s Medicaid program. Medicaid participation in aligned measure sets may help encourage provider participation in Medicaid.
- Benchmark Performance to the Commercial Market: States typically conduct a review of their aligned measure sets annually, a process which includes a performance assessment. This assessment may give Medicaid agencies access to commercial data that the agency might not track otherwise, as well as the structure to compare Medicaid quality with that of the commercial market. Furthermore, by increasing the alignment of measures used across Medicaid and commercial plans, Medicaid agencies are better able to compare performance across markets and identify measures that may require increased agency attention due to observed disparities.
Tips for State Medicaid Agencies Interested in Measure Alignment
Connecticut, Massachusetts, and Rhode Island shared the following tips for other state Medicaid agencies participating in measure alignment efforts.
- Encourage Cross-Agency Participation: Encouraging the involvement of representatives from various state agencies can greatly enrich the measure alignment process. By inviting agencies such as the state department of public health to participate in measure alignment work groups, states can ensure that measures selected not only reflect the goals of the state’s Medicaid program but also align with broader healthcare priorities and strategies within the state.
- Identify the Appropriate Medicaid Representative: The designated Medicaid agency representative should possess a deep understanding of Medicaid quality programs, regulations, and objectives. Equally important is that they are willing and able to effectively engage with other relevant stakeholders to advocate for measures that accurately reflect the Medicaid population’s needs, while also possessing influence over Medicaid quality measures and initiatives.
- Develop Robust Measure Selection Criteria: Investing time in establishing clear and comprehensive measure selection criteria sets the foundation for an objective and effective measure alignment process. Defining principles for selecting measures, such as validity, relevance, feasibility, and impact, helps guide decision-making and minimize the tendency to prioritize organizational agendas.
- Track Developmental Measures: Monitoring the progress of measures being developed ensures that states remain aware of emerging measures that might be suitable for inclusion in their quality measurement efforts. This is particularly helpful for addressing priority areas that lack viable measures or for replacing existing measures that focus on critical measure topics but have been found to be flawed, overly burdensome, or both.
Resources for States Interested in Measure Alignment
States interested in developing multi-payer aligned measure sets may wish to take advantage of SHVS’s measure alignment resources. Based on informational interviews, Connecticut, Massachusetts, and Rhode Island Medicaid staff found these resources to be valuable for building a measure set from scratch, compiling and comparing measures, learning which measures are used in other state and federal programs, and identifying homegrown measures in use in other states that could be used to fill measure set gaps.
- The Buying Value website hosts a suite of resources to support states interested in designing a measure set that will align with other priority national measure sets, as well as those that may already be in use in a given state or region.
- The Buying Value Measure Selection Tool includes major national measure sets, as of March 2023, and their component measures that are applicable for assessing primary care practices, hospitals and ACOs. The tool is designed to assist states in aligning measure sets and is updated annually.
- The Buying Value Benchmark Repository is a database of non-Healthcare Effectiveness Data and Information Set (HEDIS) and modified HEDIS measures in use by state purchasers and regional health improvement collaboratives and includes performance levels for the measures as well. The Repository is updated periodically as state purchasers and regional health improvement collaboratives submit additional measures and associated performance data. The resource, along with an online forum, allows states and regional health improvement collaboratives to identify and maximize use of performance measures that best fit their needs.
The authors thank the following state Medicaid agency representatives for participating in informational interviews and for their review of a draft of this piece: Brad Richards (CT DSS), Linda Shaughnessy (MassHealth), James Brennan (RI EOHHS), Charlie Estabrook (RI EOHHS) and Breanna Lemieux (RI EOHHS).
[i] This expert perspective was informed by informational interviews with Medicaid staff from Connecticut, Massachusetts and Rhode Island.