Federal regulations issued by the Centers for Medicare and Medicaid Services (CMS) encourage state Medicaid agencies to use external quality review organizations (EQROs) to help implement strategies for assessing the quality of services provided to Medicaid beneficiaries enrolled in managed care organizations (MCOs). The regulations, which took effect in 2003, obligate states to develop a written strategy for assessing and improving care for Medicaid beneficiaries; adopt standardized methods for quality review activities; specify mandatory and optional review activities; and provide specific protocols for conducting the activities. In late 2006, CMS built on this regulatory framework by publishing two "toolkits" designed to help states 1) develop comprehensive quality strategies and 2) implement them through contracts with their EQROs.
While the rules, regulations, and protocols governing EQROs offer states the opportunity to monitor and assess the quality of preventive and developmental services for young children enrolled in Medicaid managed care, many states have not availed themselves of this opportunity. As a 2005 Commonwealth Fund study entitled Using External Quality Review Organizations to Improve the Quality of Preventive and Developmental Services for Children indicated, states have a continuing interest in improving the quality of these services but lack specific guidance on how to do so. The CMS toolkits do not provide details regarding quality review activities for particular topics, such as preventive and developmental services. Access to additional technical resources, including specifications for an EQRO's scope of work, may help states move forward and use current regulations to monitor and assess the quality of preventive and developmental services provided to Medicaid managed care-enrolled children.
About the Study
This study is intended to build on the work of the 2005 Commonwealth Fund study mentioned above that determined the extent to which state Medicaid agencies have used or are planning to use EQROs to improve the quality of preventive and developmental services for young children. The study suggested that only a few states have used EQROs to assess and improve the quality of these services, but more states could do so if appropriate resources were available.
These resources include the influence of "champions" within the state; availability of attention-getting data demonstrating problems in providing preventive and developmental services; access to special funds related to the quality of child health; political or public perceptions about the quality of child health services; and specific recommendations from CMS, EQROs, or MCOs.
In addition, the study recommended that state Medicaid staff strengthen their knowledge base related to quality-of-care studies of preventive and developmental services. They could then draw from that base to develop appropriate language for specifying a relevant scope of work in requests for proposals (RFPs) and contracts with EQROs.
This study takes the next step by providing Medicaid agency staff with a new toolkit containing guidance on designing a scope of work for EQROs that will lead to conceptually and methodologically sound studies of the quality of preventive and developmental services for Medicaid managed care-enrolled children. State staff can use this guidance in two ways: 1) for ideas about what to include in a scope of work (as part of an RFP for a new contract or as specifications for the next year's work on an existing contract) and 2) as a source of information needed to judge bidders' responses to an RFP.
To develop this toolkit, the authors re-examined reports and RFPs gathered for the previous study and reviewed additional RFPs and contracts from 19 states (contacted because they were identified as having undertaken a pay-for-performance or value-based purchasing effort in their state Medicaid program) to identify various methods used to procure EQROs. Three states participated in follow-up interviews—Illinois, Minnesota, and Washington—either because their RFPs emphasized child health or their procurement processes were unique.
If a state decides to use an EQRO to assess child health services, it either 1) commissions the EQRO with which it contracts for all Medicaid-related quality review activities to conduct designated review activities related to child health or 2) contracts with a separate EQRO with demonstrated experience in assessing child health. The first approach is most common among states, but the EQROs with which they contract may lack substantial experience in assessing the quality of child health services. In either case, if a state wants to ensure that an EQRO will effectively assess child health services, it must ensure that the organization can demonstrate the following attributes:
- comprehensive knowledge of the Medicaid program (especially the child health components);
- ability to apply child health standards to performance measurement;
- capacity to identify relevant outcomes for the state quality improvement strategy; and
- experience in comprehensive assessment of child health services.
After a state selects an EQRO, it typically defines the scope of work by referencing the RFP. A review of state RFPs for EQRO work, however, found that the scope of work defined in most proposals is general and does not focus specifically on preventive and developmental services for children. Given that most states do not contract with an EQRO specifically for activities related to assessing these services, the scope of work is often defined in the context of a broader, overall contract. Any specifications related to preventive and developmental services are likely to be incorporated into a negotiated agreement that defines work for a particular year within a broader multiyear contract.
The RFP provides a critical opportunity for defining the activities of an EQRO. By specifying certain monitoring and assessment EQRO activities in the RFP's scope of work, states can implement goals related to improving the quality of preventive and developmental services and thus exercise the leverage needed to ensure that critical actions are taken. To define such a scope of work, states may include specifications that require EQROs to conduct the following activities related to young children in Medicaid managed care:
- determine MCO compliance with federal Medicaid managed care regulations related to the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program;
- measure the performance of a MCO in relation to ensuring the delivery of preventive and developmental services;
- recommend and subsequently evaluate a performance improvement project implemented by the state's MCOs to improve the quality of preventive and developmental services;
- assess a MCO's information system related to preventive and developmental services; and
- conduct a focused study related to preventive and developmental services.
As state staff develop the appropriate scope of work, they will build a knowledge base about child health services that will assist them in judging bidders' responses to the RFP and assessing the quality of deliverables after the contract award. States can take two other steps to contribute to a long-term commitment toward enhancing preventive and developmental services for young children enrolled in Medicaid. One involves including providers in the policymaking process. Pediatric providers are essential participants for identifying the processes needed to improve the delivery of comprehensive well-child care, particularly since the delivery of preventive and developmental services must be documented accurately.
A second step, therefore, involves planning for the use of electronic medical records to document the provision of developmental screens and their results. This emerging technology offers important opportunites for states to improve standards for providing and documenting preventive and developmental services. To the extent possible, states may want to incorporate these two steps into future contracts with EQROs.
Because preventive and developmental services promote healthy development throughout a child's life and reduce the onset of serious physical and behavioral problems, states have many compelling reasons for making long-term commitments toward improving the quality of these services for young children enrolled in Medicaid. Creating the infrastructure to monitor and assess the quality of preventive and developmental care can have a lasting impact on the health of children and their families, and thus on society as a whole.