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Quality Measurement: Past and Future
Helen Burstin, MD, MPH, FACPChief Scientific Officer, NQF
SAGES MeetingMay 15, 2015
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NQF: What We Do
Improve health and healthcare quality through measurement• Gold standard for quality measures – consensus-based
standard setting organization
• An essential forum - >400 members and >800 volunteer leaders across multiple stakeholders
• Quality leadership – convenes private and public sectors to reach consensus on healthcare’s complex and controversial issues (e.g., SES risk adjustment, linking cost and quality)
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The National Quality Strategy
HHS Value Based Payment Goals
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Legislative History of Quality
Quality measurement embraced by both sides of the aisle▫ 2008: Medicare Improvements for Patients and
Providers Act ▫ 2010: Patient Protection and Affordable Care Act (ACA)
Recent extensions:▫ 2013: American Taxpayer Relief Act - QCDR▫ 2014: Protecting Access to Medicare Act – Imaging▫ 2015: Medicare Access and CHIP Reauthorization Act –
“SGR Fix”
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SGR Fix (MACRA)
A leap on the path toward paying physicians for value not volume – it is a journey
Aligns three physician-level programs and eliminates yearly uncertainty (“the cliff”) by stabilizing payments
Longer term approach (2020 – ongoing)▫ First 5 years - two paths available to increase pay
» Reward/penalize based on the Merit-Based Incentive Payment System (MIPS)
» Participate in a qualified Alternative Payment Model (APM)
Moving Toward Efficiency & Value Measurement
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Tensions in Measurement
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IOM Report – Vital Signs
▫ Identify a set of standardized measures required at national, state, local, and institutional levels.» Limited set of measures:• Outcomes oriented• Reflective of system performance• Meaningful• Utility at multiple levels of the health care system.
▫ Recognized that any particular measure will vary in its utility at different levels (e.g., community, practice)
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US Societal Vital Signs
Life expectancy Well being Overweight and obesity Addiction behavior Unintended pregnancy Healthy communities Preventive services Care access
Patient safety Evidence based care Care match with patient
goals Personal spending burden
Measurement in Evolution
Measures that reflect higher performance (e.g., optimal performance)
Focus on outcome measures that are more patient centered (e.g., Patient Reported Outcomes)
Harmonize and align measures to reduce burden and accelerate improvement
Address disparities in all we do Build on cost and quality measurement to assess value,
including appropriateness and overuse Transition to electronic platforms and eMeasures Emerging focus on population health
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The State of eMeasurement
Difficult to identify structured fields needed for quality measurement Lack of comparability across EHR systems Data elements needed for advanced measures may not be feasible to
capture in EHRs Tracking quality and value across settings and populations limited by
lack of interoperability Limited ability to take advantage of clinical data in EHRs, registries,
and patient portals and other sources (e.g., claims, demographics) Complexity of testing across multiple EHRs; limited test beds Limited standardization of key building blocks of new eMeasure
development (e.g., data elements, value sets)
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Challenges in Measurement
Persistent measurement gaps -- especially those meaningful to surgeons and patients
Unintended consequences of measurement, including burden Appropriate level of analysis – surgeon v. institution Alignment and harmonization of measures Complex measurement science issues –
▫ SES /Risk Adjustment▫ Linking cost and quality▫ Attribution▫ Comparability ▫ Measurement for intended use
Views on Adjustment for SES and Other Demographic Factors
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OPPOSE- Some providers may deliver worse quality care to disadvantaged patients
- Adjustment could make meaningful differences in quality disappear- Worse outcomes could be expected
No expectation to improve Implies or sets a different standard
- Lack of adequate data for SES adjustment- Prefer payment approach to help safety net
SUPPORT- Risk adjustment allows for comparative performance
- A performance score alone (whether or not adjusted for SES factors) cannot identify disparities.- Hospitals caring for the disadvantaged are already being penalized.
- No evidence that disparities would be reduced through further negative financial incentives. - Lack of adjustment would continue to create a disincentive to care for the poor.
NQF Policy Change: Trial Period
The Panel recommended, and the NQF Board approved, a two-year trial period prior to a permanent change in NQF policy.
Under the new policy, adjustment of measures for SES factors is no longer prohibited.
During the trial period, if SES adjustment is determined to be appropriate for a given measure, NQF will endorse one measure with specifications to compute: ▫ SES-adjusted measure▫ Non-SES version of the measure (clinically-adjusted only)
to allow for stratification of the measure
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IOM report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, cites feedback loops as essential for continuous learning and system improvement
Continuously learning system uses information to change and improve its actions and outputs over time
Need for Ongoing Measure Feedback
More Collaboration Needed in Measurement
Prioritize Measure Gaps
Catalyze Gap Filling
Endorse Measures
Select Measures
Promote alignment
Evaluate impact
Vision for Quality Measurement
Align measures to reduce burden and accelerate improvement; end duplication within and across settings and providers▫ Reduce cacophony and increase relevance
Identify measures that are actionable, meaningful, and lead to better health outcomes
Advance measurement to accurately and reliably assess value
Achieve consistency and rigor in consumer information▫ Hospital Rankings (Health Affairs, March 2, 2015)
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