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.

Access Monitoring Review Plan (AMRP)

The Access Monitoring Review Plan (AMRP) provides an overview of access to care for North Carolina Medicaid Direct beneficiaries from 2019 through 2022. Medicaid Direct is the traditional fee-for-service Medicaid program in North Carolina. For more information, visit the NCDHHS Medicaid Direct webpage.

The AMRP analyzes the extent to which the health care access needs of Medicaid Direct beneficiaries are being met by examining provider availability and accessibility, beneficiaries’ utilization of services, health care performance measures and measures of patient experience. Access to care is important for all NC Medicaid enrollees and this report is just one tool NC Medicaid uses to track and analyze that access.

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
• Best Practices for Immunizations and Well-Child Visits Improvement for Standard Plans

Standard Plan Withhold Program

The North Carolina Department of Health and Human Services remains dedicated to improving the health of North Carolinians through an innovative, equitable, whole-person-centered and well-coordinated system of care that supports both medical and nonmedical drivers of health.

A key component of North Carolina’s Quality Strategy includes measuring and incentivizing performance improvement as part of Medicaid transformation. Withhold programs are one mechanism to encourage performance improvement in a variety of domains and have been implemented in other state Medicaid managed care programs.

In a withhold arrangement, a portion of health plans’ expected capitation payment is withheld, and plans must meet targets (e.g., quality measure performance targets) to receive withheld funds from the Department once performance is known at the conclusion of a defined performance period, typically the annual quality measurement cycle.

2024 will be the first year of NC Medicaid's Standard Plan quality withholds program. Additional details are provided in the North Carolina Medicaid Standard Plan Withhold Program Guidance.

Tele-Transformation in North Carolina 

The North Carolina Department of Health and Human Services is pleased to share a policy evaluation brief, Tele-Transformation in North Carolina: Telehealth Policy Lessons Learned During the COVID-19 Pandemic and Beyond and companion chart pack, below:

• Tele-Transformation in North Carolina: Telehealth Policy Lessons Learned During the COVID-19 Pandemic and Beyond - Sept. 2023
• Tele-Transformation in North Carolina Supporting Charts

The brief highlights North Carolina’s approach to telehealth policymaking, both in response to the COVID-19 pandemic and thereafter, to serve as a model to other states undertaking telehealth policymaking and evaluation. This brief includes:

1. An overview of North Carolina’s evolution in telehealth policy.
2. The state’s decision-making criteria used to determine temporary and permanent telehealth policy changes.
3. Key findings from the state’s evaluation of telehealth utilization between March 2020 and December 2022 (with additional detail included in the chart pack).
4. Considerations for other states.

Evaluation of the Medicaid Reform Demonstration

The Sheps Center for Health Services Research is the independent evaluator for the state’s 1115 demonstration, the North Carolina Medicaid Reform Demonstration. The evaluation assesses the impact of the transition to NC Medicaid Managed Care, the substance use disorder (SUD) component of the demonstration and the Healthy Opportunities Pilots.

For additional information and full reports, visit the Evaluation of the Medicaid Reform Demonstration page.  

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)

2021 CAHPS Survey

• Full report
• Two-page summary

2022 CAHPS Survey - One Year into Managed Care

• 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

Quality Measure Performance and Targets for the Advanced Medical Home (AMH) Measure Set

To ensure delivery of high-quality care under the managed care delivery system, 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 NC Medicaid Quality Measure Performance and Targets for the AMH Measure Set 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 (National Provider Identifier (NPI) + location code) will have its own rate that may be above or below the baseline rates provided. 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 performance on various quality measures in an effort to evaluate access to care, utilization of services, and health outcomes among beneficiaries. Performance is assessed both across years and compared to national medians. The report identifies strengths, areas of concern, and growth opportunities linked to the goals identified in the NC Medicaid Managed Care Quality Strategy. NC Medicaid will work with health plans, Local Management Entity/Managed Care Organizations (LME/MCOs), Primary Care Case Management (PCCM) entities, and providers to monitor and make improvements in quality performance year over year. 

• NC Medicaid Annual Quality Report (2018-2021) - February 2024
• NC Medicaid Annual Quality Report (2016-2019) - December 2020

External Quality Review 

• 2022-2023 EQR Technical Report - published March 2024
• 2021-2022 EQR Technical Report - published April 2023
• 2020-2021 EQR Technical Report - published March 2022 

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 based on the aims, goals and objectives outlined in the Department's Quality Strategy. It includes a list of the quality measures intended for monitoring beneficiary access to care, utilization of services, and health outcomes, and health plan performance and improvement processes. The Department will update this document as needed and on an annual basis. 

NC Medicaid Quality Measurement Technical Specifications Manual - Jan. 2024

NC Medicaid Quality Fact Sheet Series

The NC Medicaid Quality Fact Sheet series aims to detail NC Medicaid’s performance in key areas. As NC Medicaid leads many activities to survey, evaluate, and improve upon its performance, the documents below distill quality measure information for public use, providing readers insight into NC Medicaid’s performance across select domains and initiatives aimed at improving performance.

• Readers Guide on NC Medicaid Quality Fact Sheets
• Racial Disparities in Vaccination Fact Sheet - Sept. 2023
• Behavioral Health Services Fact Sheet - Oct. 2023
• Tobacco Use, Substance Use, and Substance Use Disorder Fact Sheet - Oct. 2023