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. 

Updated Quality Strategy

The updated Quality Strategy and Executive Summary are now available. Feedback can be provided by emailing Medicaid.NCEngagement@dhhs.nc.gov  with the subject line “Quality Strategy Feedback” by Jan. 6, 2023.

Quality Survey Results 

NC Medicaid has recently published results of two surveys. One measures patient experiences with their health care while the other describes findings from the baseline assessment (Year 1) of the provider experience and satisfaction with the traditional NC Medicaid Direct system, including the partnership with Community Care of North Carolina.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

The North Carolina Provider Experience Survey 

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. 

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. 

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. 3, 2022

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.

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