4. Quality Measures

4. Quality

Measures

NC Medicaid should encourage PHPs to decrease disparities in maternal health outcomes.

Implementation: • NC Medicaid should tie quality metrics in PHP contracts to tobacco cessation, perinatal depression, substance use disorder, and hypertension among pregnant and postpartum women.

North Carolina Context

NC Medicaid requires PHPs to report two Health Effectiveness Data and Information Set (HEDIS) measures, timeliness of prenatal care and postpartum care, as well as contraceptive care. It requires PHPs to report non-HEDIS measure indicating the percentage of women who had a live birth and were provided a most effective/ moderately effective contraceptive method or long-acting reversible method of contraception within 60 days of delivery.424

During the first two contract years, NC Medicaid will not tie these maternal health quality metrics to provider payment rates. Starting in the third contract year (2023-2024), NC DHHS will withhold payments for certain services that do not meet quality metrics. NC Medicaid will consider overall performance improvement for each plan’s enrolled population relative to other PHPs, as well as the relative improvement in the performance for a group with disparate outcomes when it determines rewards for quality metrics.425

Several North Carolina stakeholders reported that tying quality metrics to payments might exacerbate health inequities. If providers are concerned that their Medicaid payments might decrease, they could be selective in the patients they see; specifically, they might not see patients who are historically associated with poor maternal outcomes. However, because these payments are tied to PHPs instead of providers, there is a lower risk of adverse selection. According to stakeholder interviews, these incentives may encourage PHPs to ensure enrollees receive adequate treatment for their conditions and specifically support women of color in receiving treatment to reduce racial disparities in care. For example, even when a provider conducts a perinatal depression screening (see Screening of Perinatal Mental Health Conditions recommendation above) and a woman tests positive, there is no accountability to ensure the pregnant or postpartum woman receives adequate treatment. Thus, a large portion of people do not end up receiving treatment. Black women, specifically, are much less likely to be properly screened for depression and receive mental health treatment.426

Evidence

Quality measures present opportunities to improve maternal health among Medicaid enrollees. The Centers of Medicaid and CHIP Services published a set of recommendations on three focus areas to improve maternal and infant health: i) cesarean section births among women at low-risk for complications, ii) improved postpartum care, and iii) improved well-child visits.427 All the recommended strategies are accompanied by quality measures that can be incorporated into quality improvement systems. NC Medicaid should consider other perinatal data as additional quality metrics to withhold payments. Other perinatal data could include perinatal depression screening and followups, which PHPs are already required to report. Additionally, PHPs are required to report hypertension, tobacco cessation, and substance use screening and intervention. These outcomes—all of which contribute to maternal mortality and morbidity—should be broken down by pregnancy and postpartum status and considered as quality measures.428