Background: Methodology for Compilation of Initial Core Set
As part of their effort to use a transparent and evidence-based process for identifying an initial core set of pediatric quality measures for voluntary use by Medicaid and Children's Health Insurance Program (CHIP) programs to be posted for general comment by January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) asked the AHRQ National Advisory Council on Healthcare Research and Quality [NAC] to establish a time-limited Subcommittee on Children's Healthcare Quality Measures for Use by Medicaid and CHIP programs [SNAC]. The SNAC held public meetings and was charged with developing criteria for identifying core measures, applying those criteria to measures in use or otherwise nominated for consideration, and making recommendations to the NAC. The NAC in turn provides advice to the Director, AHRQ, and to the Secretary, U.S. Department of Health and Human Services (HHS).
The SNAC met for the first time in July 2009, to discuss and further develop a modified Delphi process to score measures known to be in use by Medicaid and CHIP programs on validity, feasibility, and importance. The SNAC also agreed to try to recommend a core measure set no greater than 25 measures. By mid-September 2009, the SNAC had 121 measures to consider during a second modified Delphi process. These 121 measures included measures that had passed criteria for validity, feasibility, and importance at the July SNAC meeting, were deemed to be in need of additional information at the July SNAC meeting, or had been nominated by SNAC members, members of the public, or identified through continuing environmental scans. Papers prepared by contractors also recommended measures for consideration. Using a second modified Delphi scoring process, SNAC members selected 65 measures as meeting criteria for validity, feasibility, and importance using the Delphi scoring system. At the September SNAC meeting, several measures that did not strictly pass the second Delphi round (e.g., had validity scores of 6 or 6.5 rather than the cutoff of 7) were added to the list of measures to be discussed and voted on during the meeting. An example of this is adolescent well-care visits. In addition, the SNAC recommended that some measures be combined and considered as single measures for purposes of SNAC voting. For example, three well-child care visit measures were combined into one measure for voting purposes (shown as PHP-9 on the SNAC recommendation table); and the CAHPS surveys for children with and without special health care needs were combined into the voting category FEC-1/FEC-5. Through a series of discussions followed by a series of votes over the day and a half meeting, the SNAC agreed to recommend to the NAC 25 measures for the initial core measure set.
The SNAC-recommended set of measures will next be discussed by the Children's Health Insurance Program Reauthorization Act (CHIPRA) Federal Quality Workgroup and reviewed by Medicaid and CHIP officials. Subsequently, a CMS-AHRQ-recommended initial core set will be forwarded to the Secretary, HHS, for her consideration and then to the Office of Management and Budget (OMB) for its review, before a final recommended set of measures is posted for general comment, by January 1, 2010.
It is important to note that the SNAC did not recommend that the measures on the list be implemented "as is." Rather, the measure denominators should be respecified so that they are feasible for use across all Medicaid and CHIP programs and by providers, consumers, and intermediaries (e.g., health plans contracting with State Medicaid programs). For example, HEDIS CAHPS (FEC 1 and 5) (Healthcare Effectiveness Data and Information Set/Consumer Assessment of Health Plans and Providers) as currently specified are currently used primarily by Medicaid managed care health plans that report to the National Committee for Quality Assurance (NCQA). The SNAC recommended that in the future, the CAHPS instruments be used by all Medicaid and CHIP programs so that family experiences of care across a broader spectrum of covered children can be understood, compared, and, when needed, acted upon. Similarly, few of the measures are used to report data that distinguish care quality by race, ethnicity, socioeconomic status, or special health care need status among children. In the future, consistent with the CHIPRA legislation, data should be collected so that meaningful comparisons can be made between children with and without special health care needs and among children of varying racial and ethnic identities.