Advancing health equity: A recommended health equity framework for accountability in Medicaid

There is growing national interest in adopting a standardized approach to health equity measurement. State Medicaid is at the forefront because it serves populations likely to have low income and low access to health care services, and to experience other negative effects of social risk factors. Almost all states have a form of managed care in place; most include risk-based arrangements that use quality measures to evaluate performance and accountability. This creates an opportunity to align quality and performance strategies with equity centered approaches to address disparities and close gaps in health care and health outcomes. States have already started down this path, but their approaches have been inconsistent—in part because there has not been a holistic evaluation of which measure concepts and targets are best suited to nuances of accountability and the needs of the Medicaid population.

This report presents a health equity measurement framework that can be used by state Medicaid programs for accountability in health plan managed care contracting. Development drew from the fields of quality measurement, public health and the social sciences. Domains were based on broad review of existing conceptual and quality models. Identification of the final proposed measures followed review of over 300 measure concepts from existing quality programs and the broader literature. Measures were selected based on their relevance, validity, reliability, feasibility, scientific soundness and relationship to outcomes. Stakeholders (e.g., Medicaid agencies, managed care organizations, patient advocates, community-based organizations, clinicians, researchers) were routinely engaged throughout the development process. Their perspectives directly informed the principles that guided development of the framework, selection and structure of domains and selection of associated measures.