First-Ever Standardized Quality Measures Set the Stage for Public-Private Alignment

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Quality Feature — April 2016 

Tex Med. 2016;112(4):59-63).

By Amy Lynn Sorrel
Associate Editor

Medicare and private payers' unveiling of the first set of standardized quality measures could be a sign they are finally following through on their promise to simplify what physicians describe as a deluge of redundant quality metrics in the complex web woven by today's pay-for-performance programs.   

For years, medicine has opposed the inconsistencies among payers in quality measurement that have detracted from patient care, in particular private plans that each use their own different metrics for the same clinical conditions. 

In February, the Core Quality Measures Collaborative, led by the Centers for Medicare & Medicaid Services (CMS) and America's Health Insurance Plans (AHIP) — and including a dozen physician organizations — released seven core sets of clinical quality measures meant to create a "uniform approach" to measuring and paying for care quality and "mak[e] physicians lives easier," states a CMS press release. (See "Core Quality Measures Collaborative.") 

As rulemaking gets under way, some unanswered questions remain as to how private payers will actually implement the measures. And although the move is not a panacea for all of the inherent flaws with quality reporting, for which medicine continues to advocate a fix, it garnered initial praise from the medical community as Medicare and private payers accelerate the shift to value-based care. 

"An Important First Step"

CMS is already on the bullet train with a goal of tying half of Medicare payments to quality by 2018. Too, officials say rulemaking on the core measures will inform the agency's parallel regulation for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), which set up a performance-based payment system to replace the Sustainable Growth Rate (SGR) formula in 2019. (See "R.I.P. SGR," June 2015 Texas Medicine, pages 26–37.) The Texas Medical Association and the American Medical Association are actively involved in filing official comments on those proposed regulations. 

Private payers are on the value-based care train, too, and plan to take a phased-in approach to implementing the core measures. 

Nearly two years in the making, "this project was not about designing new measures or measuring things that are not measured now. This process was about trimming the pool of existing measures down to those that are really important," said Houston oncologist Ronald S. Walters, MD, a member of TMA's Council on Health Care Quality. That pool already includes measures that have been validated, developed, and supported by medical specialty societies, and are already being used in existing quality programs. 

The associate vice president of medical operations and informatics at The University of Texas MD Anderson Cancer Center is a member of a National Quality Forum (NQF) Measures Application Partnership, a multistakeholder group that guides the U.S. Department of Health and Human Services on measures selection for federal programs. Although Dr. Walters did not directly participate in the collaborative, he says most of the core measures derive from the NQF's work, and the initiative falls directly in line with the forum's original charge to "make sure we have a set of measures that meets everybody's needs." 

Part of that goal includes reducing physicians' administrative workload. 

"This was designed with the best of intentions, and it is very much a step in the right direction. There is more work to be done, but this is a good partnership between CMS and private health plans to narrow the gap and the amount of work physicians have to do," Dr. Walters said. With value-based care here to stay, he adds, the partnership is an example of physicians taking a leadership role in defining future programs. 

While still a work in progress, AMA leaders agree the evidence-based metrics represent "an important first step" in establishing a model for future collaboration on performance measure alignment. As a member of the collaborative, "the AMA looks forward to continuing to participate in this initiative dedicated to alignment of quality measures because it has the potential to improve the health of the nation while also reducing administrative hassle that can lead to improved professional satisfaction and sustainability of physician practices," said AMA President Steven J. Stack, MD. 

Reduce, Refine, Relate

The collaborative developed what it calls "core measures" focused on seven areas:  

  1. Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and primary care; 
  2. Cardiology; 
  3. Gastroenterology; 
  4. HIV and hepatitis C; 
  5. Medical oncology;
  6. Obstetrics and gynecology; and 
  7. Orthopedics.   

In developing the measures, CMS says the collaborative used a set of guiding principles requiring metrics to be "meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers." (See "Governing Principles for Core Measures.")

In a June 23, 2015, Health Affairs Blog post, CMS Deputy Administrator for Innovation and Quality and Chief Medical Officer Patrick H. Conway, MD, sums up those goals in what he calls the three R's:   

  • Reduce the total number of measures by eliminating low-value metrics and introducing consistency across payers in their requirements for quality reporting;
  • Refine the measures that remain to further ease the burden of collection; and
  • Relate measures to patient health outcomes, focusing on "measures that matter."  

What CMS now calls "core measures" equate to metrics physicians already are familiar with in Medicare's Physician Quality Reporting System (PQRS), meaningful use of electronic health records (EHRs), and shared savings programs, so they should come as no surprise to physicians, says TMA Director for Clinical Advocacy Angelica Ybarra. "Doctors have seen this before," she said.  

Most of the measures are applicable in physician practices, with a few facility-based metrics, in orthopedics, for example. Some also include patient satisfaction measures.

The panel pared down the quality measures list to roughly 100 metrics across specialties, compared with about 300 in PQRS in 2016. As with Medicare's existing quality reporting programs, the collaborative will continue to add and retire core metrics as appropriate. CMS says the process will expand over time to include additional medical specialties, as well.

For the most part, physicians still will be able to report results via registry, EHRs, or claims. CMS acknowledges, however, that "a robust infrastructure to collect data on all the measures in the core set does not exist currently," and implementation of some measures in the core set "will depend on availability of such clinical data either from EHRs or registries." 

In other words, physicians may not be able to report certain measures without those tools.  

Public-Private Alignment

In addition to minimizing red tape, the measures aim to provide timely information to physicians on care quality.

Ms. Ybarra says it is unclear yet how CMS and private payers will align reporting and feedback structures, along with fair and transparent appeals processes. 

AHIP Executive Vice President Carmella Bocchino said collaborative members "have taken a leadership role in identifying measures that will drive quality improvement and outcomes for patients. This is a first step of an ongoing process to ensure both public programs and the private sector align measures and reporting, especially as we advance alternative payment models."

According to the announcement, commercial health plans participating in the collaborative represent about 70 percent of the combined population of health plan enrollees and fee-for-service Medicare patients. While Medicare already uses the core measures, commercial health plans say they will implement them as contracts come up for renewal or if existing contracts allow for modification of a performance measure set.   

While such a public-private effort was envisioned under MACRA, and likely will help physicians meet the requirements of the new Merit-Based Incentive Payment System set to take effect in 2019 (based on 2017 performance), it remains to be seen how private insurers will use the core measures in their value-based payment models, many of which are currently voluntary. Most physicians by now are familiar with Medicare's penalty-based payment structure and the many difficulties CMS has had carrying out its own programs (   

Blue Cross and Blue Shield of Texas (BCBSTX) Chief Medical Officer Dan K. McCoy, MD, told Texas Medicine: "As part of our commitment to advancing value-based care and innovative partnerships with physicians, BCBSTX will develop a timeline to transition core measures into its programs." He called the core measures project "an important product of collaboration between payers, physicians, and patient advocates to support greater value in health care through aligned measurement of quality."

A Frequently Asked Questions (FAQ) sheet posted on AHIP's website suggests health plans will incorporate the metrics into existing "benchmark" systems that "allow clinicians to compare themselves to their peers." 

At least initially, Dr. Walters anticipates the core measures will figure more prominently into so-called preferred provider designations many health plans currently use to rate physicians on quality, some of which have translated to bonus payments. The good news, he says, is physicians now will have a better idea of the measures used to determine those ratings, whereas payers today typically each have their own black box methodology.  

More Work Ahead

This first step does little to resolve other existing flaws with performance measurement that medicine has decried. These include, for instance, holding physicians accountable for patients they hardly treat and failing to adjust for factors out of physicians' control, like patients who have higher health risks or who don't follow doctors' orders. 

The FAQ sheet says: "These important areas will be addressed by the collaborative participants either through the rule-making process for CMS, or for private payers, through discussions and negotiations between clinicians and health plans." On the latter, private payers say they typically "discuss the methods for establishing realistic benchmarks and selection of actual benchmarks with their clinician partners, knowing 100-percent compliance on every measure may not be appropriate given specific patient risks." 

AMA says it "will remain engaged in this ongoing process to ensure that the core measure sets are updated and improved upon as new evidence and better measures become available," and "monitor the use of the measures in practice, in partnership with physician specialty societies, for unintended consequences and advocate for modifications as needed."

CMS' Dr. Conway writes that input from physicians and other stakeholders will be integral to the future evolution of core measure sets. "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." 

The ongoing nature of the initiative presents a big opportunity for physician leadership, Dr. Walters reiterates. In particular, he urges doctors to pay particular attention to the areas CMS has designated for future development. "That gives you an idea of what's to come. The reason it's called future development is either we don't have formal measures right now, or there isn't agreement yet on which measures should be in a core set."

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Core Quality Measures Collaborative

Physician Organization Participants 

  • American Academy of Family Physicians
  • American College of Cardiology
  • American College of Physicians
  • CAPG, The Voice of Accountable Physician Groups
  • American Academy of Orthopaedic Surgeons
  • American Gastroenterological Association
  • American Heart Association
  • American Medical Association
  • American Society of Clinical Oncology
  • Council of Medical Specialty Societies
  • HIV Medicine Association
  • Infectious Diseases Society of America
  • American Academy of Pediatrics 

Health Plan Participants 

  • Aetna 
  • Anthem
  • AmeriHealth Caritas Family of Companies  
  • Blue Care Network
  • Blue Cross Blue Shield Association   
  • Blue Cross Blue Shield of Massachusetts 
  • Cambia Health Solutions 
  • Cigna 
  • Group Health Cooperative 
  • Harvard Pilgrim Health Care 
  • Health Care Service Corporation (parent company of Blue Cross and Blue Shield of Texas) 
  • HealthPartners 
  • Highmark
  • Humana, Inc. 
  • Kaiser Permanente 
  • UnitedHealth Group 

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Governing Principles for Core Measures  

  1. Measure sets must be aimed at achieving the three-part aim of the National Quality Strategy: better care, healthier people and communities, and more affordable care.
  2. National Quality Forum (NQF)-endorsed measures are preferred. In the absence of NQF endorsement, measures must be tested for validity and reliability in a manner consistent with the NQF process, where applicable.
  3. Data collection and reporting must be minimal.
  4. Overuse and underuse measures should both be included.
  5. Measure sets for clinicians should be limited to fewer than 15 measures, when possible.
  6. Measures that are currently in use by physicians, measure patient outcomes, and have the ability to drive improvement are preferred.
  7. Measures that cut across multiple conditions to reflect a domain of quality (e.g., patient experience with care, patient safety, functional status, managing transitions of care, medication reconciliation) are preferred.
  8. Measures should be meaningful to and usable by consumers and also applicable to different patient populations.
  9. Patient outcome measures should allow careful and prudent physicians to attain success.
  10. As with all measures, those that reform payment or delivery systems should measure clinical quality, patient experience, and costs. 

Source: Health Affairs Blog, June 23, 2015 


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Last Updated On

May 25, 2016