Using Medicaid and CHIP claims data to support pediatric quality measurement: lessons from 3 centers of excellence in measure development.

Gidengil C1, Mangione-Smith R2, Bailey LC3, Cawthon ML4, McGlynn EA5, Nakamura MM6, Schiff J7, Schuster MA8, Schneider EC9.

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Abstract

OBJECTIVE:

We sought to explore the claims data-related issues relevant to quality measure development for Medicaid and the Children's Health Insurance Program (CHIP), illustrating the challenges encountered and solutions developed around 3 distinct performance measure topics: care coordination for children with complex needs, quality of care for high-prevalence conditions, and hospital readmissions.

METHODS:

Each of 3 centers of excellence presents an example that illustrates the challenges of using claims data for quality measurement.

RESULTS:

Our Centers of Excellence in pediatric quality measurement used innovative methods to develop algorithms that use Medicaid claims data to identify children with complex needs; overcome some shortcomings of existing data for measuring quality of care for common conditions such as otitis media; and identify readmissions after hospitalizations for lower respiratory infections.

CONCLUSIONS:

Our experience constructing quality measure specifications using claims data suggests that it will be challenging to measure key quality of care constructs for Medicaid-insured children at a national level in a timely and consistent way. Without better data to underpin pediatric quality measurement, Medicaid and CHIP will have difficulty using some existing measures for accountability, value-based purchasing, and quality improvement both across states and within states.