4.2 Quality Measures

anywhere, including in EDs. In a separate interview, the state’s Sickle Cell Educator Counselors confirmed that many of the state’s SCD centers produce provider-signed pain management plans for their patients to present in the ED.

Additional Considerations

The addition of “people with sickle cell disease” to the list of priority populations will task PHPs to collaborate with providers to bring resources to SCD and reverse the neglect the disease has historically received. This will ensure that people with SCD who have complex care needs will consistently receive care management and individualized care plans that improve their health outcomes, regardless of the PHP they are enrolled in. The state’s PHP contract already requires care management and individualized care plans for other complex populations and acknowledges that “people with sickle cell disease” could be a priority population as determined by PHPs, so creating a standalone designation of “people with sickle cell disease” as a priority population is a change that can be achieved in the short-term. It is unclear which PHPs already designate people with SCD as a priority population. Member handbooks for the plans do not mention comprehensive assessments and individualized care plans for enrollees with SCD, but interviews with some plans demonstrate that they recognize enrollees with SCD have complex health care needs that require comprehensive support.

NC Medicaid should assess PHP performance on outcomes for people with SCD.

Implementation: • NC Medicaid should convene a workgroup of stakeholders, including people with SCD, to determine appropriate quality measures for SCD. • NC Medicaid should add quality measures for SCD to “Required PHP Quality Metrics” that measure PHP performance.

North Carolina Context

NC Medicaid’s PHP contract requires PHPs to report a set of quality and administrative measures to assess the PHP’s processes and performance and, “beginning in Contract Year 3, the Department may implement withhold measures based on quality measures used to administer a PHP quality withhold/incentive program”.285 The list of required PHP quality metrics totals 66 quality measures and includes measures like “Medication Management for People with Asthma”, “Comprehensive Diabetes Care”, “Statin Therapy for Patients with Cardiovascular Disease”, among others. NC DHHS has the right to add additional quality metrics, providing opportunities to leverage quality metrics to identify weaknesses and prioritize populations.

NC Medicaid’s PHP contract does not include any quality measures that assess the PHP’s performance with SCD. Without quality measures and the quantification of outcomes and disparities for patients with SCD, it is difficult to determine where existing gaps are and develop effective interventions.

Quality measures improve processes of care and adherence to guideline-based process measures.286 Furthermore, quality measures provide an opportunity to increase transparency into existing disparities of care and ultimately reduce disparities. Many sickle cell-specific quality measures have been developed in recent years that examine sickle cell care delivery, care use, patient experience, and outcomes. The National Quality Forum (NQF) has endorsed three quality measures for SCD care, including: i) NQF #2797, “Transcranial Doppler Ultrasonography Screening among Children with Sickle Cell Anemia”;287 ii) NQF #3166, “Antibiotic Prophylaxis Among Children with Sickle Cell Anemia”;288 and iii) NQF #3595, “Hydroxyurea Use Among Children with Sickle Cell Anemia.”289 In an interview with providers at a comprehensive sickle cell center in North Carolina, one provider identified adherence to medical visits and medication as simple quality metrics that improve health outcomes for people with SCD. NQF has several medication adherence measures for specific classes of medication therapy (but not SCD specifically) that can serve as examples.290

Example: Quality Measures in Michigan

In an interview with a PHP representative in North Carolina, the interviewee explained that Medicaid has minimal quality measures and many PHPs are already collecting their own quality measures independent of Medicaid requirements to ensure their enrollee population is healthy. They noted it is not an issue for plans to incorporate additional quality measures, which NC Medicaid already has plans to do. Existing SCD quality measures are a starting point for NC DHHS to create a stakeholder group (that includes people with SCD) with the goal of determining appropriate SCD quality measures that should be incorporated into the PHP contract to foster high-quality SCD care and identify opportunities for improvement. Thus, the addition of SCD quality measures is achievable in the medium-term.

The population of people with SCD is small, so there may be methodological challenges when trying to measure PHP performance. Programs that assess providers’ performance relative to an expected target or comparison group can be biased by random variation.292 Thus, NC Medicaid should pursue guardrails and appropriate statistical approaches in its design of quality measures. Some strategies include assessing prior variations and risk adjusting for case-mix.293

In FY2020, Michigan implemented a Medicaid quality improvement project focused on pediatric SCD that impacts its Children’s Special Health Care Services population; the project assessed three pediatric SCD quality measures: i) Proportion of Pediatric Members (ages 2 -15 years) with Sickle Cell Anemia with a Completed Transcranial Doppler (TCD) screening; ii) Proportion of Pediatric Members with Sickle Cell Anemia <5 years old with at least 300 days of Dispensed antibiotics; and iii) Proportion of Pediatric Members (ages 1 through 17) with Sickle Cell Anemia with at least 300 days of Dispensed Hydroxyurea.291