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For Physician Quality Measures, CMS Has Received the Message: Simpler is Better

February 18, 2016
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Late last week, I read a fantastic article in the New England Journal of Medicine about standardizing patient outcome measures, with the broad purpose of the piece to urge federal healthcare bodies to agree on and implement streamlined patient outcome measures for each medical condition.

Indeed, the authors of the piece—Michael E. Porter, Ph.D., Stefan Larsson, M.D., Ph.D., and Thomas H. Lee, M.D.—attested that as healthcare shifts from the volume of services delivered to the value created for patients, measurement of outcomes that matter to patients, aside from survival, still remains limited. They noted that of the 1,958 quality indicators in the National Quality Measures Clearinghouse, for example, only 139 (7 percent) actually measure outcomes, and only 32 (less than 2 percent) measure patient-reported outcomes. Defaulting to measurement of discrete processes is understandable, given the historical organization of healthcare delivery around specialty services and fee-for-service payments, the authors wrote.

They continued, “Yet process measurement has had limited effect on value. Such measures receive little attention from patients, who are interested in results. Process measures don’t truly differentiate among providers, so incentives for improvement are limited. Nor does improving process compliance from 95 percent to 98 percent matter much for outcomes. Yet the effort required to measure processes and ensure compliance consumes organizations’ resources and attention, leading to clinician skepticism about the value of measurement, which spills over to outcomes measurement.”

When asked about different quality measures for different Medicare reporting programs, physicians often groan before giving the common example of one payer in an accountable care organization (ACO) having marginally different definitions of hemoglobin A1C (HbA1c) control for a Medicare beneficiary diabetic patient from another payer in another program. Oftentimes in fact, providers are submitting dozens, if not hundreds—depending on their size—of reports per month, and the duplications, manual extraction, and complexity, create a huge burden on them.

The authors of the NEJM piece concluded, “We predict that a time will soon come when it will be hard to believe that measurement of outcomes that mattered to patients was rare in 2016 — and organizations that measured them each did it in their own way. Universal measurement and reporting of outcomes won’t happen overnight. But we believe that agreeing on and implementing respected standard sets of outcomes for each medical condition is a practical and decisive step in accelerating value improvement in healthcare. This is an agenda whose time has come.”

Could that process have already started? Just days after the NEJM article was published, the Centers for Medicare and Medicaid Services (CMS) and America’s Health Insurance Plans (AHIP), in collaboration, for the first time, released seven sets of standardized clinical quality measures for physician quality programs that support multi-payer alignment. The core measure sets, developed by the new Core Quality Measures Collaborative, which includes CMS, the American Academy of Family Physicians and the National Partnership for Women & Families, among others, are intended to promote alignment of quality measures for the practitioner community or group practice level accountability and are in the following areas: ACOs, Patient-Centered Medical Homes (PCMH), and Primary Care; Cardiology; Gastroenterology; HIV and Hepatitis C; Medical Oncology; Obstetrics and Gynecology; and Orthopedics.

According to a CMS press release, partners in the Collaborative recognize that physicians and other clinicians must currently report multiple quality measures to different entities. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. To address this problem, CMS, commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible.

What’s more, the Collaborative plans to add more measure sets and update the current measure sets over time using the notice and public comment rulemaking process. “In the U.S. healthcare system, where we are moving to measure and pay for quality, patients and care providers deserve a uniform approach to measure quality,” CMS Acting Administrator Andy Slavitt said in a Feb. 16 statement. “This agreement today will reduce unnecessary burden for physicians and accelerate the country's movement to better quality.”

It should be noted that CMS is already using measures from the each of the core sets. According to federal agency officials, several of the measures included in the core set require clinical data extracted from electronic health records (EHRs), are self-reported by providers, or rely on registries. While some plans and providers may be able to collect certain clinical data, a robust infrastructure to collect data on all the measures in the core set does not exist currently. The implementation of some measures in the core set will depend on availability of such clinical data either from EHRs or registries.  Providers and payers will need to work together to create a reporting infrastructure for such measures, CMS said.