Healthcare quality analysts say favoritism toward incumbents and fear of disrupting the status quo are major reasons why the same groups are repeatedly selected to develop and maintain CMS' quality measures.
It's easier for incumbents to be selected over newcomers because of how the contracts are designed, said Francois de Brantes, senior vice president of commercial business development at healthcare consultancy Remedy Partners.
The contracts the CMS uses for quality measure development are called umbrella contracts, which means applicants are only given a broad description of projects they may be working on. After they are selected, the awardees bid on projects that come up.
In a copy of the 2013 Measure and Instrument Development and Support umbrella contract, also called an indefinite delivery/indefinite quantity contract, the CMS said the purpose of the umbrella contract is to “procure the services of one or more MIDS contractors by establishing the fundamental activities that may be awarded in subsequent individual task orders.”
Because the umbrella contract is a broad stroke of all possible tasks the CMS might want, applicants need an enormous amount of expertise and infrastructure, de Brantes said.
“The decks are stacked from the get-go. When you start looking at the requirements that you have to meet to be considered for any of these contracts, it whittles down to a few organizations,” he said. “You have a few organizations who develop a reputation, who have an expertise and initially get contracts—and once you have it, it's almost impossible to displace you.”
Dr. Harlan Krumholz, director of the Center for Outcomes Research and Evaluation, which is affiliated with the Yale School of Medicine and Yale New Haven Hospital and a big recipient of the contracts, said the institution doesn't have any advantage when it's selected by the CMS for contracts.
“When we started we were not incumbents. We had to work hard to get in a position to win contracts and show what we could do. It has taken 20-plus years to get in the position we are in. We believe in a fair process—one in which the government and the public get the best service for the best price,” he wrote in an email.
The CMS follows federal acquisition regulations for all contracts. Although a CMS official said the awardees of agency contracts must have experience in measure development, she added that incumbents don't have “a leg up. We are not saying ahead of time that Yale is getting this contract.” She said that the CMS is “looking for new organizations we haven't worked with before, because they can bring innovative ideas.”
The CMS may also not be interested in shaking up its list of contractors because it's not advantageous for them to do so at this point, said Dr. Karen Joynt Maddox, an assistant professor of medicine at the Washington University School of Medicine in St. Louis. Many of these measures are embedded in value-based purchasing programs.
“I would suspect that giving their contracts out to a small group of contractors guarantees that things aren't going to change very much, and that is probably what they want,” Maddox said. “The instability to the industry of moving from one measure to another would be unbelievable.”
Another problem is that academics may be turned off by the stipulations tied to the CMS contract, said Andy Ryan, associate professor of health management and policy at the University of Michigan.
Of the 31 groups in the newest MIDS contract, just two are academic institutions: Yale and the University of Michigan. The rest are either research groups or consultants.
The CMS asks contractors to allow the agency to control how the data that results from the contract are delivered, documented and publicized. Even though his employer—the University of Michigan—contracts with the CMS, Ryan said he's not involved in the work. “As academics, we publish, that is our mission, that is the core of who we are. When you can't do that under a contract, it makes the contract far less appealing.”
To get at these problems, quality researchers suggest the CMS diversify. “They need to have a more competitive renewal process and spread the measure development to multiple groups and institutions, often having multiple groups do the same work in different ways,” said Karl Bilimoria, a health services and quality improvement researcher at Northwestern Medicine, in an email.