Editor’s note: The full list of authors for the Core Quality Measures Collaborative Workgroup is included at the end of the blog post.
In today’s health care system, physicians are faced with an unprecedented number of quality measures required by different entities. Payment is pivoting away from traditional reimbursement models toward value-based health care, where value is a function of both quality and cost. Patients are making an about-face from traditionally passive receivers of health care to informed consumers with expectations of transparency. Payers and employer groups are demanding accountability for how their dollars are being spent.
In this changing environment, health care quality measurement must evolve to meet stakeholder expectations. Current quality measurements provide a solid foundation upon which to build the kind of quality measurement that includes manageable reporting requirements for providers, alignment by reporting entities, and a focus on health outcomes that are more meaningful to consumers, providers, and payers, than many process-based measures.
To realize this vision, America’s Health Insurance Plans (AHIP) and its member plans’ Chief Medical Officers convened leaders from The Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF), as well as national physician organizations, to form The Core Quality Measures Collaborative in 2014.
The payers in the Collaborative represent approximately 70 percent of the combined population of health plans’ enrollees and fee-for-service Medicare beneficiaries. Recently, the Collaborative launched an initiative to assemble a set of core quality measures. These core measures will align with the National Quality Strategy priorities of better care, healthier people and communities, and more affordable care.
Our goal is to promote a simplified and consistent process across public and private payers by reducing the total number of measures, refining the measures, and relating measures to patient health — known as the 3Rs (reduce, refine, and relate) (Figure 1).
Figure 1. Core Quality Measures Collaborative 3Rs — Reduce, Refine, and Relate
This effort is an important first step. By creating the relationships at the heart of our Collaborative, we can begin an iterative process that will build core measure sets. It will expand to encompass other stakeholders, including additional medical specialties, employer groups, consumers, patient advocacy groups, and allied health professional organizations.
The State of Quality Measurement: Gains and Opportunities
Quality measurement has helped to improve many aspects of health care delivery and change the culture of the health care ecosystem. By annually tracking more than 200 measures since 2003, the Agency for Healthcare Research and Quality (AHRQ) reports that the quality of health care is improving.
This is evidenced by the retirement of certain quality measures that have effectively “topped out,” such as Aspirin at Arrival for Acute Myocardial Infarction. While the improvements in quality are to be celebrated, AHRQ qualifies the status of health care quality in the US as “fair,” suggesting that the existing framework for quality measurement is ready for the next evolution of refinement.
Too Many to Handle
Today’s number of quality measures reaches well into the thousands. The NQF’s important work of endorsing and maintaining measure sets reduces this number into the hundreds, but significant opportunities remain to reduce variability and align measure sets. A recent study of 48 state and regional measures sets identified 509 distinct measures in use, with only 20 percent of the measures used in more than one program and not a single measure common across all programs.
CMS has aligned measures across federal programs significantly in the last three years but with over 30 different programs that use quality measures, further alignment is necessary. The volume, redundancy, and variability of quality measures result in administrative burden for providers, a burden which increases with each additional measure required by each payer or plan.
Hazards of Measure Variability by Payer
Frequently, payers focus on similar quality topics but may utilize different measures (e.g. different readmission measures). Perhaps even more administratively complex and burdensome to providers is the fact that payers may have different measures for the same clinical conditions, such as multiple different measures for cardiology and orthopedic conditions. These inconsistencies limit the effectiveness of analysis for providers, patients, and payers.
A provider is charged with providing quality care to his or her entire patient population, regardless of payer. Varied, disparate quality and performance reports prevent a whole-picture view of the population’s health and incentivize a fragmented approach to care. Likewise, public reporting of quality data can misinform the consumer, preventing them from making an informed choice. Such fragmentation erodes the utility and confidence in the value of quality reports.
Processes Overshadow Outcomes
Quality improvement measures seek to both inform providers’ quality improvement work, and the patient, on the value of care they receive. To date, quality measurement has largely enforced and incentivized delivery of evidence-based care through measurement of compliance with recommended care.
Today, however, these measures still focus on processes, such as whether a person with diabetes had their hemoglobin A1c (a person’s average blood sugar level over the past three months) measured. Although process measures provide some insight into the provider’s provision of care, they do not answer the most important question: did the care result in an optimal health outcome?
Instead of quantifying the percentage of people with diabetes who had their hemoglobin A1c measured, the focus should be on the percentage of people with diabetes who effectively control their disease and complications. In a health care ecosystem where patients are responsible consumers, outcomes measures must provide needed transparency and serve as the most effective tool for quality comparisons.
Missing The Provider Mark
Trends in care delivery models show an increasing emphasis on interprofessional collaboration, particularly for the most complex patients. Other trends point to a rise in value-based payments and importance of accountable care. The two require adjustments in not only what is measured, but who is measured. If a measure is used for provider accountability, it must be for a process or outcome that the provider can actually affect.
Moreover, the measure needs to be specific enough (e.g., evidence-based cancer screening or hypertension control) that the provider can understand how to act to improve it. In considering a new quality measurement framework, the level of measurement (provider vs. team vs. organization-level) is as important as the subject of measurement.
What About the Specialists?
Specialists outnumber generalists by 26 percent (636 per 1 million persons versus 472 per 1 million); however, quality measurement tends to focus on the primary care setting. Though major specialties do have some measures that apply to them, these measures tend to be process-focused and are less represented in large-scale payment and quality measurement programs. For example, the Electronic Health Record (EHR) Incentive Program requires there be an “exclusion” option, by which some specialty providers are exempt from reporting on nine quality measures due to lack of relevance.
This scarcity of usable quality measures in certain specialties further limits much of the information that consumers want and need to make rational health care decisions.
Assembling Core Quality Measure Sets
To determine a framework for a set of core quality measures, the Core Quality Measures Collaborative identified specific governing principles that advance the 3Rs and will be used as a framework for future iterations of measure sets and implementing core measures.
Table 1. Governing Principles for Core Measures
Note: NQF measure evaluation criteria include: evidence-base for the measure, reliability, validity, etc.
With the aims and governing principles in place, physician organizations have joined the Collaborative to help assemble the core measures by specialty. Although it would be desirable to engage the medical profession and other stakeholders as broadly as possible, such an effort would be difficult at the outset.
Instead, the Collaborative has engaged physician organizations such as the American Academy of Family Physicians (AAFP), American Congress of Obstetricians and Gynecologists (ACOG), American College of Cardiology (ACC), and American Academy of Orthopedic Surgeons (AAOS). These groups have already taken major steps in quality measurement development and implementation and have begun the process of active collaboration.
Over time, additional medical specialties, employer groups, consumers, patient advocacy groups, allied health professional organizations, and other stakeholder groups will be included in the process of quality measurement selection and improvement. This will be an iterative process that will build in a gradual, controlled but purposeful way.
As the efforts to assemble the core measures are underway, Table 2 illustrates how existing measures are being evaluated against the governing principles. The commentary for each represents the beginning of a dialogue leading up to the planned release of the core measure sets by the end of June 2015 and refinement over time.
Table 2. Selected Examples of NQF-Endorsed Measures Under Evaluation for Core Measure Sets
Note: This table is not a comprehensive list, for illustrative purposes only. Source: National Quality Forum. Quality Positioning System.
The primary focus of this Collaborative is achieving consensus on a core set of measures and establishing a process through which continual refinement and modifications to the core set occurs. The emphasis is on the strategic aspects of measurement and not necessarily on the operational details of measurement and reporting. Operational topics outside the scope of this effort include establishing performance targets and processes for ensuring reliable reporting of quality data. Such issues will be determined through ongoing dialogue between payer organizations and the providers in their network.
The Path Forward
The success of this collaboration is as dependent on the adoption and iterative updates of the core measures, as it is on the measures themselves. Accordingly, the core measures will be deliberately phased-in, beginning with the specialties aligned with the pioneering physician organizations and expanding over time to other specialties and stakeholder groups.
This phase-in approach will allow payers to evaluate the timing of adoption of these core measures through the procedures used in their programs and contracts over time. For example, under CMS programs, new measures are adopted after undergoing notice and comment rulemaking.
As the core quality measures are adopted, physicians and payers alike will have the opportunity to influence future updates to the measures, including addressing measure gaps, through their respective professional organizations. This collaborative process and feedback mechanism facilitates adoption, integral input from stakeholders, and an iterative process for rapid progress. Providers and other stakeholders will be integral to future evolution of core measure sets.
Aligning employer and other regulatory requirements with these measure sets will also be critical to their success, allowing resources to be focused on areas of quality that matter.
Finally, with aligned measures and meaningful reporting, assessment, and evaluation tools should be used to determine both the benefit and the burden of the measures. These assessments should focus on the changes in patient health outcomes relative to the opportunity and implementation costs.
These assessments will allow measures to be evaluated for retirement when: the evidentiary basis for a measure has changed; there is sustained high performance on a measure and achievement of a targeted benchmark; the cost of collecting and measurement outweighs the clinical utility of the measure; or the measure has been demonstrated to have minimal impact on health outcomes and status.
This Collaborative challenges all members of the health care community to join in our commitment to quality “measures that matter,” within the framework of the 3Rs — Reduce, Refine, and Relate. This effort represents a historic level of collaboration on quality measure alignment which should benefit the whole health system. This work is essential to improve health and health care and enable a shift towards a health care system of improved outcomes and higher value.
The views in this manuscript represent the authors and not necessarily the views or policies of their respective organizations.
The Core Quality Measures Collaborative Workgroup
Kate Goodrich, Centers for Medicare and Medicaid Services; Andrew Baskin, Aetna; Roy A. Beveridge and Laura E. Happe, Humana, Inc.; Patrick Courneya, Kaiser Permanente; John Fallon, Blue Cross Blue Shield of Massachusetts; Charles J. Fazio, HealthPartners; Donald R. Fischer, Highmark; Andrea D. Gelzer, The AmeriHealth Caritas Family of Companies; Trent Haywood, BlueCross BlueShield Association; Marc D. Keshishian, Blue Care Network; Alan Muney, Cigna; Sam R. Nussbaum, Anthem; Stephen L. Ondra and Brad Bare, Health Care Service Corporation; Richard Popiel, Cambia Health Solutions; Lewis G. Sandy, UnitedHealth Group; Michael S. Sherman, Harvard Pilgrim Health Care; Paul Sherman, Group Health Cooperative; and Carmella Bocchino and Aparna Higgins, America’s Health Insurance Plans Inc.