CMS' focus on 'meaningful measures' faces hurdles

A CMS effort to turn the corner on achieving widespread use of outcomes-based quality measures is getting mixed reviews from providers and payers.

Industry stakeholders support recent efforts by the CMS to focus on quality measures that are "meaningful" to clinicians and their patients. But questions remain about how effective the agency's work will be as uncertainty persists around which measures are actually the most valuable.

"I think (the initiative) is representative of a broader trend," said Dr. Kedar Mate, chief innovation and education officer at the Institute for Healthcare Improvement. "The quality measurement movement is moving in the direction of outcomes-based measurement."

The initiative encouraged Carolinas HealthCare System, which already uses outcome measures extensively. "We may be further along in the maturation of working on these things," said Dr. James Hunter, chief medical officer of the Charlotte, N.C.-based system. The initiative "gave us reassurance that we are heading in the right direction and a framework for some of the work we had already been doing," Hunter said.

The not-for-profit has created outcomes-based quality- improvement programs such as its Carolinas Heart Success program, which uses a 30-day hospital readmissions measure to track how heart failure patients are managing their disease.

A multidisciplinary team of dietitians, pharmacists, patient navigators, social workers and nurses provide follow-up care after patients leave the hospital to prevent unnecessary and costly readmissions.

Since the Heart Success program launched in 2011, the readmission rate for heart failure patients has decreased from 19% to 15%, well below the national average of about 25%.

"Heart failure is a very difficult disease to manage, and really the key for our success was to provide wraparound services for our patients," said Dr. Sanjeev Gulati, medical director of heart failure and transplant services at Carolinas' Sanger Heart & Vascular Institute.

Even though outcome measures are deployed by health plans and providers to better coordinate and manage complex patients, industry executives have some problems with the CMS' effort.

During a November webinar to discuss the Meaningful Measures initiative, providers questioned if it will truly reduce the burden because it didn't appear to narrow down which measures are truly "meaningful."

Indeed, the core tenets of the initiative touch on broad aspects of care deemed to be meaningful and as a result should be measured, such as "equity of care" and "appropriate use of healthcare."

Some questioned how such generalities lessen the reporting burden. "There is no reduction whatsoever," said Robert Berenson, a health policy fellow at the Urban Institute. The core objectives "include virtually everything, so they haven't narrowed down anything."

The IHI's Mate said the lack of consensus in healthcare around what quality measures are meaningful creates the risk that the shift to outcome measures will unnecessarily bloat the number of measures. Mate argued that the best way to find out the most meaningful measures is to ask patients what matters to them. "What we want to do is measure the things that matter the most, and the only judge and jury of that are the patients we serve," he said.

Collecting data provided by patients, often called patient-reported outcome measures, is seen as the future of outcome measurement by providers and payers alike.

The industry is at various stages of adopting patient-reported outcomes. Blue Cross and Blue Shield of Louisiana is currently in the "planning" stages of ways to measure if and how a patient's quality of life has improved after healthcare services, said Dr. Vindell Washington, chief medical officer.

Geisinger Health System, an integrated delivery system based in Danville, Pa., uses more than 15 questionnaires across its organization to collect patient-reported outcome measures. "Simplifying and focusing on the most important outcomes that resonate with patients and doctors—that is an important step in the right direction," said Dr. Neil Martin, Geisinger's chief quality officer.

Process measures will likely be more and more unnecessary as outcome measures continue to grow in use "because the outcome measures have the process within them," said Dr. Andrew Zinkel, associate medical director for quality at HealthPartners.

Mate said removing measures when new ones are added is vital. "The biggest risk is not really solving the problem but layering the outcome measure on top of abundant process and activity measures—that's a recipe of greater burden and waste, and not necessarily helping."

It appears the CMS will be more particular about which measures it adds. The CMS suggested just 32 quality measures in November, down from the nearly 100 measures the agency recommended the year before. The list of 32 not only focuses more on outcomes, but the CMS recommended that several patient-reported outcome measures be included in its programs as well—like change in functional status after a knee replacement or change in leg pain after lumbar spine-fusion surgery.

The CMS' moves are seen as positive signs for the healthcare industry that substantial change in quality measurement is underway, but the work of eliminating and scrutinizing measures needs to continue, Mate said. "There should be a well-organized clinically informed process for removing measures—take a couple off the docket when possible whenever new ones are introduced."