Using Medicaid and CHIP claims data to support pediatric quality measurement: lessons from 3 centers of excellence in measure development

Acad Pediatr. 2014 Sep-Oct;14(5 Suppl):S76-81. doi: 10.1016/j.acap.2014.06.014.


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.

Keywords: CHIP; Medicaid; quality measurement; value-based purchasing.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Algorithms
  • Child
  • Child Health Services / standards*
  • Child Welfare / legislation & jurisprudence*
  • Humans
  • Insurance Claim Review*
  • Insurance, Health / legislation & jurisprudence*
  • Medicaid*
  • Pediatrics / standards*
  • Quality Assurance, Health Care / methods*
  • Quality Indicators, Health Care
  • United States