Advancing Health Equity: A New Measurement Framework for Medicaid

September 15, 2022 · NCQA Communications

The Bottom Line:

Download Advancing Health Equity: A Recommended Measurement Framework for Accountability in Medicaid.

Register for the October 11 webinar, A National Conversation on a Measurement Framework for Accountability in Medicaid.

Advancing health equity is a priority for all health systems, but it is especially important for Medicaid, since its enrollees are more likely to have low incomes and experience negative health disparities. Quality measurement is a key accountability tool in most Medicaid programs. To help center equity in state and health plan accountability programs, NCQA has released a measurement framework to promote health equity in managed care contracts.

Funded by the California Health Care Foundation, Advancing Health Equity: A Recommended Measurement Framework for Accountability in Medicaid, is a key piece of a larger project, that standardizes health equity measurement. The project focuses on Medicaid, but many elements apply across the health care ecosystem.

We examined peer-reviewed and grey literature, conceptual and measurement models, policy statements, and state contracting documents, and engaged expert stakeholders to develop the framework. Our final framework covers six domains, each containing associated quality measures:

• Equitable Social Interventions.
• Equitable Access to Care.
• Equitable High-Quality Clinical Care.
• Equitable Experience of Care.
• Equitable Structures of Care.
• Overall Well-Being.

The domains span the care continuum, from addressing social needs to assessing overall well-being—the overarching principle. The domains overlap to signify that achieving equitable health is an intersectional venture. Overall Well-Being, the heart of the framework, is included to highlight its integrative nature across all domains. The framework sets minimum expectations for equitable quality through a common measure set.

A Good Start on a Complicated Topic

Communities that experience health inequities are often faced with social conditions that create barriers to achieving their best health. These can include food insecurity, housing instability, limited community resources, and structural and interpersonal racism. All of these conditions and their effects have been highlighted and intensified by the COVID-19 pandemic. High-quality care should consider the context in which the patient lives and treats them accordingly. All quality frameworks should include equity to be true to its name. So, an equity-oriented measurement framework is one way to address these issues by recognizing the full spectrum of the drivers of health and well-being, and ensuring that the health care system provides resources, clinical care and positive experiences that support patients.

Based on stakeholder input, the framework prioritizes racial equity, but is designed to expand beyond race and ethnicity. For example, as data collection around sexual orientation, gender identity and disability improve, states and health plans can apply the strategies outlined in this framework to address broader inequities.

To account for many factors that drive health, our framework also includes measures of:

• Maternal and child health.
• Behavioral health.
• Chronic disease.
• Home- and community-based services.
• Other upstream and downstream elements of health.

The framework builds on common themes in quality measurement while incorporating novel concepts and measures critical to accountability. The domains of Equitable Access to Care, Equitable High-Quality Clinical Care and Equitable Experiences of care include measures of access, chronic disease and patient experience. Measures related to social determinants of health, organizational systems and resources and a person’s overall health are not as common in current quality measurement programs. However, stakeholders across a range of perspectives agreed they are important for a complete assessment of equitable health care, so we also included the domains of Equitable Social Interventions, Equitable Structures of Care and Overall Well-Being.

What’s Next?

Download Advancing Health Equity: A Recommended Measurement Framework for Accountability in Medicaid.

Register for A National Conversation on a Measurement Framework for Accountability in Medicaid, a webinar taking place on October 11, 2022.

We expect to assess scoring methods for evaluating equity measures, including for composite measures. Look for news about that later this year.

This health equity measurement framework was designed to evolve with the measure and data environment. While many measures of access, chronic disease and health care experiences exist, they may not yet incorporate concepts most relevant to communities or to equitable outcomes. Measures of social needs and health plans’ structural capacity for improving equity are rare. As these areas develop, so can this framework, retaining the domains while refining the measures associated with them to continue to advance the goal of achieving equitable, high quality, health care for all.

NCQA thanks our colleagues at the California Health Care Foundation for partnering with us in this important and rewarding work.