Mandatory Reporting on Medicaid Quality Measures: What Did Congress Intend?

In August, CMS posted its proposed rule to codify Congressional action taken in 2018 to mandate state reporting of the Child Core Set and the Adult Behavioral Health Core Set of quality measures in Medicaid and CHIP, starting in 2024. Until 2024, state reporting on the core sets is voluntary. I did a quick scan of the proposed rule in this blog when it was released and commended CMS on progress toward stratification of quality measures by race, ethnicity, sex, age, rural/urban status, disability, language, or such other factors, which are critical to addressing health disparities.

Upon closer examination, we have one significant disagreement with the proposed rule. It would give the Secretary open-ended latitude in determining which measures the states would be mandated to report in any given year. Moreover, based on the proposed rule, it’s unclear when or if we would ever get to full mandatory reporting.

Here’s the background: in 2018, Congress included a requirement for mandatory state reporting all of the Child Core Set measures in the Bipartisan Budget Act of 2018 starting in 2024. That action was followed with a requirement in the Support Act of 2018 for mandatory state reporting of the Behavioral Health Core Set measures. The two laws amended Sections 1139A and 1139B of the Social Security Act, respectively, and each is clear in mandating states to report ALL Child Core Set and ALL behavioral health measures in the Adult Core Set, starting in fiscal year 2024.

Instead, the proposed rule would give the Secretary discretion to delay state reporting of mandatory measures. We do not believe Congress intended to grant such authority to the Secretary given the plain reading of the statute that states must report on “all” of the Child Core Set and Adult Behavioral Health Core Set measures beginning with fiscal year 2024 annual state reports. However, we do believe the Secretary may have more flexibility to phase in national publication of state-level data. But even with that, we are concerned about the lack of urgency in achieving transparency and full accountability in reporting state-level data for all mandated core measures and recommend that any phase-in of national publication of state-level data be limited to no more than the third year after mandatory reporting is required for the existing measures, or as measures are added to or significantly changed in the mandatory core sets. A phase-in of national publication allows time for states to test and refine reporting on mandatory measures. But, as we’ve seen with voluntary reporting, there is no urgency to refine reporting if the data never see the light of day.

Otherwise, we are in general agreement with most other sections in the proposed rule, including codifying the current process for annual review of the core sets in consultation with the states and “interested parties.” This process helps to establish priorities for measure development, identify gaps, recommend measures to be added or removed, and ensure that all measures reflect an evidence-based process including testing and validation. I have served as a member of the annual review workgroup, facilitated by Mathematica on behalf of CMS, for the past four years and know that the process has become more rigorous in setting minimum standards before changes to the core measures are considered and vetted by the cross-sector workgroup.

One thing I was reminded of in reviewing the relevant statutory language is that the initial implementation of the Child Core Set requires that it include a “duration of children’s health insurance coverage over a 12-month period” measure. Yet, here we are 11 years later and there is no duration of coverage measure on the core sets. This is relevant to quality reporting because most health quality measures require a minimum period of coverage continuity. Without continuous coverage, quality reporting is incomplete and does not always reflect the experience of enrollees who churn off the program, and who are most at risk of skipping preventive care and delaying needed care due to cost and lack of coverage. We recommended in our comments on the rule that the Secretary prioritize the development, testing, and implementation of such a duration of coverage measure as soon as possible and no later than mandatory reporting for 2024.

Comments on the proposed rule are due on October 21, 2022 before midnight ET and can be submitted by clicking on the “submit a formal comment” button here. You can find our comments here. If you would like to learn more about the Child Core Set and quality improvement in Medicaid and CHIP, check out our Medicaid Learning Lab quality session and this primer on quality. If you’re interested in seeing how your state scores on reported child core set measures, check out our State Data Hub.