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Improving Care for Medicaid Beneficiaries with Complex Care Needs and High Costs: Quality Measures

Beneficiaries with Complex Care Needs and High Costs (BCNs) are Medicaid beneficiaries who, because of their health and/or social conditions, are likely to experience high levels of costly but preventable service utilization, and whose care patterns and costs are potentially “impactable” (CMCS July 24, 2013 Informational Bulletin (PDF, 423.03 KB) ). This subset of Medicaid beneficiaries (“super-utilizers”) is an extremely heterogeneous group with varying medical, behavioral, and psycho-social needs.

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners, Brandeis University and the National Committee for Quality Assurance, to develop two measures for the CMS Medicaid Innovation Accelerator Program (IAP):

  1. All-cause emergency department utilization rate for Medicaid beneficiaries with complex care needs and high costs (BCN-1).
  2. All-cause inpatient admission rate for Medicaid beneficiaries with complex care needs and high costs (BCN-2).

All-cause emergency department utilization rate for Medicaid beneficiaries with complex care needs and high costs: all-cause emergency department (ED) utilization rate for adult Medicaid beneficiaries who meet BCN population eligibility criteria. For the purpose of this measure, BCNs are defined as Medicaid beneficiaries who are age 18 to 64 during the measure testing period and who have at least one inpatient admission and at least two chronic conditions, as defined by the Chronic Conditions Data Warehouse (CCW), in the past 12 months. Beneficiaries dually enrolled in Medicaid and Medicare and beneficiaries who had fewer than 10 months of Medicaid eligibility in the previous 12 months are not included in the analytic sample because we did not have enough utilization data to include them in testing. The measure is calculated as the number of ED visits per 1,000 member months.

All-cause inpatient admission rate for Medicaid beneficiaries with complex care needs and high costs: all-cause inpatient admission rate for adult Medicaid beneficiaries who meet BCN population eligibility criteria. For the purpose of this measure, BCNs are defined as Medicaid beneficiaries who are age 18 to 64 during the measure testing period and who have at least one inpatient admission and at least two chronic conditions, as defined by the Chronic Conditions Data Warehouse (CCW), in the past 12 months. Beneficiaries dually enrolled in Medicaid and Medicare and beneficiaries who had fewer than 10 months of Medicaid eligibility in the previous 12 months are not included in the analytic sample because we did not have enough utilization data to include them in testing. The measure is calculated as the number of inpatient admissions per 1,000 member months.

Measure Dissemination Webinar

Webinar on New Quality Measures for Medicaid Beneficiaries with Complex or Integrated Care Needs and Medicaid Beneficiaries Who Use Home and Community-Based Services  (PDF 812.54 KB)