For more than a year, top officials from Medicare, the nation's largest health plans, medical societies and major employer and consumer groups hammered away at a dreadful task: getting everyone to agree to use identical quality measures for the treatment of heart disease, cancer and other common conditions.
Previous attempts have failed, but this one did not. Participants in this effort, called the Core Quality Measures Collaborative , announced the first fruits of their work on Tuesday.
Now the real negotiations begin.
The collaborative released a list of standard quality measures for primary and accountable care and separate lists for six medical specialties. Medicare and commercial insurance companies pledged to use the standards in a growing number of physician and hospital contracts that tie quality performance to payment. That could reduce the burden and confusion doctors face as they track and report on a growing and diverse number of quality measures. Patients, meanwhile, should find it easier to compare doctors on quality.
But first, Medicare has to modify regulations that prescribe different quality measures or that don't include those adopted in the new standardized sets. Private insurers must negotiate the quality measures in each contract as it comes up for renewal.
In addition to accountable care organizations and primary care, CMS aims to streamline its quality measures for cardiology, gastroenterology, HIV and hepatitis C, obstetrics and gynecology, medical oncology and orthopedics.
Whether the new standards are widely adopted will depend on public rulemaking and the degree to which standards are included in contracts hammered out by health plans, physicians and hospitals. Though widely endorsed, the switch to the consensus measures in commercial plans is voluntary.
“What we don't want to do is to unilaterally make a change,” said Dr. Andrew Baskin, national medical director for quality and provider performance measurement at Aetna. The Hartford, Conn.-based insurer won't require use of the new standard measures but will use them as a “starting point” as the insurer enters or renews contracts.
Contract terms for quality measures vary for many reasons, and some reasons are more compelling than others. One is the evolving science around measuring healthcare processes and outcomes. Another, however, is that providers prefer targets they can achieve.
At this point, the science has significant limitations. “That's the number one, two and three reasons” that so many different measures are in use, said Dana Gelb Safran, chief performance measurement and improvement officer for Blue Cross Blue Shield of Massachusetts. She has been part of previous failed attempts to standardize measures. “There hasn't been one that has this promise,” she said.
Policymakers, industry officials, consumer advocates and quality experts are all embracing the new standards as an important step. But they also agree that much more research is needed to improve and expand the quality metrics used in healthcare. “This was essentially the first cut,” Baskin said.
New research will prompt changes to quality measures endorsed or recommended by medical societies or various quality evaluation organizations, such as the National Quality Forum, which served as a technical adviser to the collaborative.
Indeed, the quality standards for cardiology underscore that point. The collaborative endorsed two different measures for hypertension, one slightly more aggressive than the other. That's because the science behind the measure was evolving as standards were being drafted, said Dr. Paul Casale, the American College of Cardiology representative to the collaborative.
The ACC and the American Heart Association urged members to use the more aggressive standard until new research is evaluated. That is underway, and the collaborative will reevaluate its standards once the research is finished. That's why cardiologists agreed to incorporate both measures in the standard. “We didn't want it to stop the process,” Casale said.
Another reason so many different quality metrics are in play is that insurers and doctors try to incorporate measures that reflect the needs of a particular patient population or that drive certain quality improvement efforts.
Dr. Mark Jarrett, chief medical officer for Northwell Health, formerly North Shore-LIJ Health System, said the system looks for quality measures “where we can drive improvement,” or to target performance that is “not where we think it should be.” Incorporating those targets into contracts steers limited resources and attention to those priorities, he said.
Other providers try to negotiate performance targets in their contracts that they know they can achieve Whatever the motivation, a preference for certain metrics may create some tension as health plans press for what the collaborative has recognized as the best available measures.
The participants, however, sought to identify measures that could be easily collected by a wide range of providers. They nixed measures they thought might be unfair or too hard, said Dr. Michael Sherman, senior vice president and chief medical officer at insurer Harvard Pilgrim Health Care, who was part of the workgroup that developed the consensus measures.
The promise of uniformity and clarity should be a big draw for providers. Quality reporting required by Medicare, Medicaid and private health plans has accelerated in recent years, and that trend is expected to continue. Half of Medicare spending outside of managed care will be tied to quality performance by 2018, HHS said last year. Aetna said it will shift 75% of its business into such contracts by 2020.
“There are too many variations of measures that are being used, which causes confusion on the part of consumers and purchasers and causes unnecessary administrative work on behalf of providers,” said Bill Kramer, executive director of national health policy for the Pacific Business Group on Health, which took part in the collaborative.
Employer and consumer groups are eager to see the standards widely embraced, but they also want to see them evolve.
“It's where we need to start,” said Carol Sakala, director of childbirth connection programs at the National Partnership for Women & Families.
The next step, Sakala said, will be to collect more data that are relevant to healthcare consumers, such as how quickly patients recover from surgery. The collaborative recently created a new group—which includes Sakala and representatives of consumers, employers, health plans, health systems and medical professionals—to look at measures for outcomes reported by patients.
“There are just so many areas where we don't have good measures that this time,” Sakala said.