'Tis the season when CMS looks at a long list of proposed quality measures, any one of which might reveal which healthcare providers are delivering care that is very, very good.
Once again, it's the merry measure maker's favorite time of year.
'Tis the season when the Centers for Medicare & Medicaid Services wraps up a big jolly package of paradigms, any one of which might reveal which healthcare providers are delivering care that is very, very good…
…and which are performing, well, not so good.
The CMS package is called the MUC, for the Measures Under Consideration (PDF) report for 2013, which federal law mandates that CMS publish each December 1.
This year, the third year of the MUC, the 407-page opus lists 234 protocols that CMS or any number of medical groups, quality organizations, or other federal agencies want to see codified in pay for reporting or pay for performance algorithms, or just for public reporting, period.
These stakeholders made a good enough case to CMS that a candidate protocol is a plausible if not excellent method to rate quality, and thus deserves special scrutiny and testing by experts to see if it's really ready for prime time.
This year, the candidate measures purport to extend beyond the current fare of pneumonia, heart attack and stroke measures. Providers would be scored on whether they administered appropriate evaluations and treatments to patients with cancer or cataract and retinal problems, diabetes, stroke, and many other diseases and conditions.
There's even a proposal to gauge adequacy of services for those who might be at risk of violent behavior.
This bundle of measures will be vetted over the next six weeks by dozens of members of the National Quality Forum's Measure Application Partnership (MAP), which is an assembly of various committees, each of which specializes in a particular measure area.
The MAP is under CMS contract, by the authority of the Patient Protection and Affordable Care Act, to do this task each year, and send a report with its recommendations back to CMS by February after collecting hundreds of stakeholder comments.
"We vet them, make sure they make sense, comb through and make recommendations back to CMS on the ones that we think are the highest priority and the most useful," says William Kramer, a member of the MAP Coordinating Committee who is a former Kaiser Permanente CFO and now National Policy Executive Director for the Pacific Business Group on Health.
Some measures will be deemed so important, he says, they will be fast-tracked for NQF endorsement, which speeds their way to use in various performance programs, like those under discussion in the bipartisan plan to replace the Sustainable Growth Rate and current physician fee schedules with those that reward doctors as much as 12% of their pay for good performance on certain measures, such as those measuring functional outcomes, by 2021.
"The drafts have included a schedule of how measures would be used, with some emphasis on outcome measures, not just process measures," he says.
Now, you may be thinking to yourself something along these lines: Good Grief. Don't we already have enough measures woven into our current regulatory incentive programs to drive providers into the holiday punch bowl?
Kramer acknowledges that there are a lot of measures now in play. But no one feels they're necessarily the best measures or only measures to rate care. And that's what's great about the MAP, and this year's MUC, he says.
Mapping quality measures
There's lots of variety in the MUC. For example, the American College of Emergency Physicians thinks a good measure of quality within emergency departments would be to count the percentage of patients with minor head injury who got a head CT. A higher number would mean poorer quality of care because those patients probably didn't really need that expensive test, which wasted resources and could have revealed clinically insignificant findings.
More proposed measures: The National Committee for Quality Assurance proposes that a physician who discusses with his or her patients at least once a year the importance of regular exercise is a better doctor than a physician who doesn't broach that topic.
A sign of poor care might be noticed if a facility or a gastroenterologist had a higher percentage of patients admitted within days of an outpatient endoscopy or colonoscopy, a measure suggested by CMS. This could indicate problems with perforations or infections, and would be a marker of poorer quality of care.
Services provided in a variety of settings made it onto the MUC this time, from ambulatory surgery and dialysis centers to home health and long-term hospital care, in addition to emergency departments and cancer treatment centers.
This year more than in the past, the MUC includes more than a dozen functional outcome measures that are reported by the patient, which many physicians, payers, and patients say are much more important than process measures that currently dominate quality programs today. For example, patients with congestive heart failure might be asked to define a target improvement goal, and the measure would rate providers on whether the patients met that goal they set for themselves.
Another such measure counts the number of total hip arthroplasty patients who assessed themselves as having improved function after surgery.
These patient-reported measures are important because they come directly from the patient's experience and perceptions, "not just from information from clinical records or claims data," Kramer says.
Additionally, Kramer says, "there's more measures of cost and efficiency, or total resource use" in the MUC. For example, for several diseases and conditions providers would be rated on the cost and use of resources during an episode of care—and whether a care team talked with patients about the cost of their prescription drugs.
Consideration of how much healthcare costs is emerging as a moare important area of quality of care. Karen Adams, the NQF's vice president for national priorities, says that over the years, the MAP "has tried to advance measures that matter a lot to patients and their families about whether or not they receive care coordination, patient-centered care. And there are measures of affordability."
"We're not where we want to be just yet, but certainly that's the direction we're going as we continue to evolve … because these are important gap areas that we're moving to fill, measures at the population health level," she says.
Updating quality measures
The MUC process is not just about adding more measures. Part of the job, Adams explains, is the removal of measures that the committees and stakeholders believe are outdated or no longer valid. Those measures, the committee decides, "become retired," she says.
And there is also a harmonization process under way, to take into account numerous quality measure that are similar and currently requiring repetitive reporting by providers, Adams says. Those measures need synchronization, with committee members choosing the best ones.
Of course not all 234 candidate proposals will be approved. But not to worry. There's always next December 1 and the MUC for 2014.