Using Medicaid and CHIP Claims Data to Support Pediatric Quality Measurement

Lessons from 3 Centers of Excellence in Measure Development

Published in: Academic Pediatrics, v. 14, no. 5, Supplement, Sep./Oct. 2014, p. S76-S81

by Courtney A. Gidengil, Rita Mangione-Smith, L. Charles Bailey, Mary Lawrence Cawthon, Elizabeth A. McGlynn, Mari M. Nakamura, Jeffrey Schiff, Mark A. Schuster, Eric C. Schneider

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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.

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