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.
Nonetheless, with the proposed rule for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) due this spring, this is certainly a welcomed first step in what will undoubtedly be a long journey. Indeed, CMS officials noted that this work is informing its implementation of MACRA through its measure development plan and required rulemaking. To this end, CMS’ recently-released Quality Measure Development plan, currently under review for comment, was informed by the development of the core measure sets and identification of key measure gaps, the agency said.
Certainly, the standardizing of these seven sets of clinical quality measures should be well-received by the provider community. Leslie Kriegstein, interim vice president of public policy, at the College of Healthcare Information Management Executives (CHIME) said in an emailed response when asked her reaction to the Collaborative, “The future of value-based reimbursement is contingent on the ability to measure performance and outcomes, thus efforts to improve alignment and simplify quality measurement across both federal programs and private payer initiatives, like that which CMS announced with AHIP, will be tremendously important as the nation’s healthcare providers transition into alternative payment models.”
Kriegstein continued, “Solving the myriad of challenges associated with quality reporting will take time and while the announcement pertains to only a small subset of the quality metrics our members capture an report, any opportunity to increase efficiency in quality reporting will begin alleviate the current strains the process puts on provider time and resources.”
Blair Childs, senior vice president of public affairs at the Charlotte, N.C.-based Premier healthcare alliance, agreed with Kriegstein. He said, “Historically, performance measures have varied widely across payers. In the public sector, there are more than 500 different state and regional quality measures, only 20 percent of which were used by more than one program. Private insurers contribute their own unique evaluation measures to the mix, for an additional 550 different measures. These conflicting and often contradictory measures not only lead to consumer confusion and provider ‘measurement fatigue, but also add considerable administrative expense.”
Going back to the diabetes example, for the ACO/PCMH/primary care measures, as revealed by CMS yesterday, the consensus calls for data to be included for: “The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent hemoglobin A1C level during the measurement year was greater than 9 percent (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.”
I, for one, think providers will applaud that the 9 percent figure will now be the standard across the board, rather than 8 percent for one entity, 8.5 percent for another, and 9 for yet another. In a teleconference call announcing the Collaborative on Feb. 16, Slavitt said, per media reports, “People in healthcare universally ask for one thing: ‘simplify, simplify, simplify.’" Finally, as the NEJM authors unintentionally foreshadowed, simplification could be upon us.