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CMS and AHIP, together with physician groups and other stakeholders, announce alignment and simplification of quality measures.
In a move that industry watchers are saying was “long overdue,” the Centers for Medicare & Medicaid Services (CMS) and America’s Health Insurance Plans (AHIP) released seven sets of clinical quality measures that support multi-payer alignment, for the first time, on core measures primarily for physician quality programs.
The agreement is part of a broad Core Quality Measures Collaborative that includes CMS, AHIP, the American Academy of Family Physicians and the National Partnership for Women and Families. The National Quality Forum, an endorsement body for industry quality standards, is a technical adviser.
The core measures are in the following seven areas:
The collaborative plans to add more measure sets and update the current measure sets over time.
The collaborative’s work is informing CMS’s implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) through its measure development plan and required rulemaking, and is part of CMS’s commitment to ensuring programs work for providers while keeping the focus on improved quality of care for patients.
Next: Industry experts react
A report from the Washington, D.C.-based Bipartisan Policy Center pointed out that providers are experiencing increased frustration because of the requirement to report on measures for multiple programs and payers.
“We are very pleased that they have finally begun to narrow and simplify this system-though it is only a start,” says G. William Hoagland, senior vice president, Bipartisan Policy Center. “For providers, carriers, etc., this is a major plus in simplifying a terribly over-complex system. The proliferation of measures is/has resulted in measurement fatigue.”
This is a good first step that public and private payers, and all types of providers should embrace and build upon to transform healthcare from fee-for-service to population health management, says Joseph M. Mack, MPA, Joseph Mack & Associates. “Transforming the collaborative’s standards data into information enables physicians to evaluate standardized performance criteria, and to take remedial steps to improve performance and outcomes of individual and groups of physicians,” he says.
“Physicians in all settings must understand how the use of information obtained from standardized measures will help them be the best, most cost-effective physicians,” Mack adds. “The challenge is to transcend the measures established by the collaborative to move from mere compliance with standards, to transforming care delivery in a creative transformational way. The initial measures are meant as a start, but focus principally on existing high-cost easier tracked measures, through existing organizational forms [e.g., hospitals or clinicians]. Apart from certain standards in the Collaborative ACO and PCMH Core Measures, there is initially little focus on alternative delivery models or the patient centered medical home approach for population health management.”
Next: Certain healthcare systems more likely to succeed than others
According to Mack, provided the collaborative’s standards are normalized to remove unintended consequences, organizations that have robust IT infrastructures, experience and expertise in continuous process improvement, are better equipped initially to manage and reduce their clinical and financial risk of implementing these initial standards, as well as the eventual pay-for-performance requirements for adherence to these and other measures into the short term future.
“Once these and other standards have been adopted and implemented by public and private payers, the initial savings arbitrage of existing cost overruns will diminish,” he says. “Involvement of patients in their own healthcare outcomes will becoming increasingly important to payers and providers focused on pay for performance.”
According to Hoagland, this effort is in response to “major complaints by providers and carriers,” and is based in part, he says, on an analysis of 48 state and regional measure sets (across 25 states and three regional collaboratives) that found that there was little alignment across measure sets and that most programs modify a portion of their measures, which leads to an even greater lack of alignment.
Specifically, the analysis found that across the 48 measure sets, 1,367 measures were in use, while only 20% of all measures were used by more than one program. Similarly a study of 29 private health plans found that of the 550 distinct measures identified, there was little consistency with the public-program measures. The volume of measures was so great that organizations devoted many resources to gathering them; and many metrics were not associated with the desired patient outcome.
“Simply stated, the move from fee-for-service to alternative payment systems that reward value, not volume, necessitated the development of quality standards,” Hoagland says. “MACRA last year, and the ACA [Affordable Care Act] earlier, clearly has driven this action.”
Next: How the measures will affect reimbursement
As the collaborative’s activities mature, how data will be used for reimbursement by public and private payers will become the challenge, says Mack.
“Non-constituent groups will attempt to influence measures created and defined by the collaborative since they will be used to increase or decrease reimbursement,” Mack says. “These non-collaborative members will seek to join the collaborative or influence decision making, especially at the public level, by demanding participation in measure testing and public commentary about applicability to their own constituent organizations and groups.”
The collaborative member constituents “must work with their IT vendors to ensure that the core measure sets are loaded into their electronic health records [EHRs] so that they can begin to capture, measure and improve performance prior to being compelled to do so by public and private payers through increases or decreases to reimbursement,” Mack says.
What remains to be seen is whether the collaboration will provide a process and platform to transition, says Mack. It also remains to be seen how quickly the collaborative will transition from transactional activities-such as defining goals and tasks and working within the existing organizational structures of the constituent members-to standardizing rules and procedures for achieving true transformational change in the structure, culture and delivery of healthcare away from fee for service toward population health.
“Moreover, how will data defined by the collaborative be translated to empower patients with making their own healthcare decisions?” he asks.
Standardization is a good first step, he says, adding that all stakeholders should be proactive in building strong primary care bases (if applicable), in creating integrated health information technology infrastructures that enable them to apply and measure the collaborative’s criteria, and in establishing or improving processes aimed at improving these measures. “Eventually, as the collaborative’s standards mature, reimbursement will shift from fee-for-service to pay for performance and provider payment risk,” he says.