Getting quality measures in alignment a difficult task

While much of the attention this week from the Trump administration's executive order on transparency focused on prices, there's also a section of it that calls for alignment of quality measures across all federal healthcare programs. Provider stakeholders and quality researchers support the effort but say it will be a heavy lift.

Tucked within the executive order, the administration notes that HHS, the Defense Department and the Veterans Affairs Department in the next six months will develop a strategy, called the Health Quality Roadmap, that will detail plans to consolidate quality measures publicly reported across Medicare, Medicaid, the Children's Health Insurance Program, the health insurance marketplace, the Military Health System and the VA health system. Additionally, the roadmap will include plans to eliminate "low-value or counterproductive measures" from quality programs.

Provider stakeholder groups overwhelmingly support the order. They argue it will help consumers make better healthcare decisions while at the same time aligning safety and quality goals across the industry, likely spurring more innovation and improvement.

"By having a common measurement set we will identify places where the VA and DOD facilities are really outstanding and be able to learn from them and adopt some of those strategies to provide better care," said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. "Anytime you add a large number of hospitals to a program you have this richness of information coming into the system that can help us all get better."

Ambulatory Surgery Center Association CEO Bill Prentice said his organization has been advocating for alignment on quality measures across the industry for years. Ambulatory surgery centers publicly report to the CMS different measures than are required of hospitals and nursing homes.

"There needs to be a breakdown of the silos between the different quality reporting programs to make it easier for patients to compare quality across settings," he said.

Alignment of measures may even remove the burden of "chasing metrics," said Dr. David Levine, senior vice president of advanced analytics and informatics at group purchasing organization Vizient. Health system quality departments now spend a lot of time figuring out the differences in design of quality measures in the many federal programs to ensure they will do well.

"It will allow hospitals and clinicians to really work on true improvement instead of spending so much time trying to understand how it's measured," he said.

But coming up with a strategy, especially in six months, isn't going to be easy, provider groups and analysts say.

"It's a tough thing to do. Six months is really ambitious," said Dr. Mark Friedberg, senior physician policy researcher at the RAND Corp.

One of the main challenges the agencies will likely face is agreeing on a set of common measures that benefit beneficiaries in all groups. For instance, Medicaid and VA beneficiaries have different conditions and concerns than Medicare and commercially insured patients.

"They have to decide where there are areas to really synchronize and where there are differences," Friedberg said.

A good place to start is with measures currently in use that are condition-specific, Levine said.

Ideally, patients look at publicly reported quality measures for pre-planned services like a knee replacement. "What will be key is to really focus on what will be helpful to a consumer to make meaningful choices," he said.

Measures that are confusing for patients and even the providers should be avoided, Levine added. For instance, the PSI 90 measure, a composite hospital measure of many safety events, has been controversial and patients won't understand what it means. It's currently used by the CMS to assign hospitals star ratings, which are posted on Hospital Compare website for consumers.

The agencies may even face pushback from measurement developers throughout the process, Friedberg said. Some groups receive hefty contracts from the agency to develop quality measures, two of which are academic health systems. Yale New Haven Health and the University of Michigan are among CMS' contractors. If some measures are eliminated as a result of the federal effort, developers may strongly advocate against it, he added. RAND, Friedberg's employer, is also a CMS contractor.

There are also worries that measures important to patients will be removed from public reporting. The CMS has already removed some measures from quality reporting programs as part of its Meaningful Measures initiative. That faced opposition.

"We do have some concerns that (the administration) will be hesitant to publicly report the most important quality measures," said Leah Binder, CEO of the Leapfrog Group. She added that it will be essential for the agencies to gather feedback from the public and employers on what measures are most important to them.

Another barrier is the continued disagreement around risk-adjustment of outcome measures. Although much of the industry supports the movement to outcome measures, consensus about how to properly risk-adjust those measures hasn't yet been achieved and "we aren't going to fix that in the next six months," Friedberg said.

Finally, achieving alignment across settings is probably going to take a significant amount of time considering that some measures will need to be created. Most quality measures in use today were developed with the intent they'd be used in specific settings, not across settings, Prentice said. They also weren't made with the patient in mind.

"I don't think these (quality) programs were ever created with the thought that they were going to be used predominantly to help guide patients where they were going to get care. This is an opportunity to frame these programs with that goal in mind," he added.