Using quality measures to monitor and evaluate the impact of a pharmacy carve-in implemented through an 1115(a) demonstration waiver: The Texas healthcare transformation and quality improvement program

Effective March 1, 2012, pharmacy benefits were carved-in for both established and new managed care service delivery areas in Texas. While risk-based managed care is common among state Medicaid programs, the implications of a pharmacy carve-in in terms of quality of care are mixed. Texas Health and Human Services Commission (Texas) is monitoring multiple quality indicators to evaluate the short-term impact and intermediate outcomes of this policy change on Medicaid beneficiaries with persistent asthma, a condition for which medication is an integral component of the disease management plan. A pre/post study design allows Texas to measure change using two HEDIS measures: The use of appropriate medications for people with asthma (ASM) and the asthma admission rate. Additionally, prospective monitoring of a new HEDIS measure will be included from 2012 forward: The asthma medication ratio (AMR). From 2008-2011, approximately 94% of primary care case management (PCCM) and managed care beneficiaries used appropriate asthma medications. In 2012, there were slight changes to the ASM criteria and approximately 91% of managed care beneficiaries used appropriate asthma medications, surpassing Texas dashboard requirements and the HEDIS mean for this indicator. Asthma admission rates were reported per 100,000 eligible clients: From 2009 to 2011, the rate decreased from 162 to 112 and 128 to 100 in the PCCM and managed care models, respectively. In 2012, the asthma admission rate was 6%, reflecting a change from a population-based to a discharge-based metric. Established in 2012, the baseline level for the AMR indicated that 67% of clients with persistent asthma had an AMR of 0.5 or greater. Monitoring multiple quality outcomes is important to determine short-term outcomes and inform overall evaluation efforts of a policy change of this magnitude. Texas will continue to monitor and evaluate the implications of the pharmacy carve-in throughout the five-year demonstration period to inform future policy actions.