Quality Management and Improvement

The Department’s goal is to improve the health of North Carolinians through an innovative, whole-person centered, and well-coordinated system of care and measurement of quality, which addresses both medical and non-medical drivers of health.

As North Carolina transitions to NC Medicaid Managed Care, the Department will work with Prepaid Health Plans (PHPs) to develop a data-driven, outcomes-based continuous quality improvement process, This will:

• Focus on rigorous outcome measurement compared to relevant targets and benchmarks,
• Promote equity through reduction or elimination of health disparities, and
• Appropriately reward PHPs and, in turn, providers for advancing quality goals and health outcomes.

Quality Strategy

The Department’s Quality Strategy details NC Medicaid Managed Care aims, goals and objectives for quality management and improvement and details specific quality improvement (QI) initiatives that are priorities for the Department. 

• NC Medicaid Managed Care Quality Strategy
• Executive Summary

Community Health Worker Strategy for Public Comment

NCDHHS has published North Carolina Medicaid’s CHW Strategy Guidance Paper to seek feedback on the vision and approach of this strategy developed to further drive the integration of CHWs into NC Medicaid’s managed care system. NC Medicaid welcomes feedback and input on all components of this strategy by emailing Medicaid.NCEngagement@dhhs.nc.gov (subject line “CHW Feedback”) by March 15, 2023.

For more information, please see Medicaid bulletin article NC Medicaid’s Community Health Worker Strategy Guidance Paper.

Quality Survey Results 

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a patient experience survey that serves as a national standard for measuring and reporting respondents’ experiences with their health care. The Medicaid Provider Experience Survey evaluates the impact of the North Carolina Medicaid Transformation on primary care and obstetrics/gynecology (Ob/Gyn) practices that contract with NC Medicaid.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

• Full report
• Two-page summary

2022 Medicaid Provider Experience Survey – One Year into Managed Care

• Full Report
• Summary

Baseline Medicaid Provider Experience Survey 

• Full report 
• Two-page summary

NC Medicaid Managed Care Qualitative Evaluation

Qualitative interviews with Prepaid Health Plans (PHPs) and provider organizations are part of a larger multi-year evaluation of the transition from NC Medicaid Direct (fee-for-service) to NC Medicaid Managed Care under the 1115 demonstration waiver. Summaries of qualitative evaluation findings to date are provided below:

Demonstration Year 3 Summary – Providers

Demonstration Year 3 Summary – PHPs

Demonstration Year 4 Summary – Providers

2022 and 2023 Advanced Medical Home Measure Targets

To ensure delivery of high-quality care under the managed care delivery system, the NC DHHS has developed the NC Medicaid Managed Care Quality Strategy and identified a set of quality metrics that it will use to assess health plans’ performance across their populations. The Department has identified a subset of these measures for health plans to use to monitor Advanced Medical Home (AMH) performance and calculate AMH performance incentive payments. 

The first quality performance period for AMHs began in January 2022. 

• The 2022 and 2023 AMH Measure Targets table provides baseline data and targets for health plans. 
• NC Medicaid does NOT set targets for AMHs. 

These baseline data and targets are shared as a reference for AMHs. An AMH practice (NPI + location) will have its own rate that may be above or below the baseline state median rate. AMHs should negotiate target performance rates with health plans. Additional information and resources for AMHs are available on the NC Medicaid Advanced Medical Home webpage. 

Quality and Accountability

While the mechanics of reimbursement for health care are changing, the goal of NC Medicaid remains improving beneficiaries’ health and well-being by delivering the right care, in the right place, at the right time. In designing this transition, the Department is committed to leveraging engagement through the managed care program with PHPs and their contracted providers to improve the quality of health care beneficiaries receive.

North Carolina identified targeted quality indicators that will serve as guides for the Department, contracted plans and providers. These performance indicators will be crucial to assess the success of the new approach.

Provider Health Plan Quality Performance and Accountability Concept Paper

Annual Quality Report

The NC Medicaid Annual Quality report assesses NC Medicaid’s 2016 -2019 performance on quality measures linked to the goals identified in the NC Medicaid Managed Care Quality Strategy. NC Medicaid will work with health plans, Local Management Entities – Managed Care Organizations (LME-MCOs), Primary Care Case Management (PCCM) entities and providers to focus on significant improvements in quality performance year over year.

NC Medicaid Annual Quality Report - December 2020

External Quality Review 

2020-2021 EQR Technical Report

The EQR Technical Report is a program-wide detailed technical report summarizing the findings of the annual external quality review and quality of care across all PHPs. It includes an executive summary of the objectives of the EQR as well as a description of the EQR process, including data collection tools, documents requested, offsite and onsite activities, a description of the data reviewed and a summary of findings and conclusions drawn from the data. 

Smarter Spending: Value-Based Purchasing under Managed Care

NC Medicaid will increasingly tie payment to value and will support PHP and provider contracting flexibility that helps providers deliver care in new ways. PHPs will play a critical role in driving forward Medicaid’s Value-Based Purchasing (VBP) goals. 

Learn more about Value-Based Purchasing.

Quality Measurement Technical Specifications

This document provides an overview of the Department’s plans for promoting high-quality care through NC Medicaid Managed Care, and updates the information found in the PHP Quality Performance and Accountability Concept Paper. It includes a list of the quality measures intended for use in the early years of the program. The Department will update this document as needed and on an annual basis.

Medicaid Managed Care Quality Measurement Technical Specifications Manual - Jan. 31, 2023