July 28, 2015
Are CMS's Quality Measures Helping or Hurting?

You can’t change what you don’t measure, goes the saying, and the importance of this notion could not be more true in healthcare. Particularly when you’re talking about the kinds of sometimes-revolutionary systemic changes that have been brought about by and because of the passage of the Affordable Care Act. Newly institutionalized concepts such as value-based purchasing and measuring patient satisfaction have been a lot to manage, to be sure, but it seems that hospitals’ and providers’ efforts are starting to pay off.

The Impact Assessment

The Centers for Medicare and Medicaid Services (CMS) has issued the 2015 National Impact Assessment of Quality Measures Report, a comprehensive assessment of quality measures used by CMS to improve healthcare delivery and achieve better clinical care, smarter spending and a healthier population. Specifically, the report outlines the performance on quality measures over time and improvements achieved. Findings from the report include research on 25 CMS quality programs and hundreds of quality measures from 2006 to 2013, and builds on the prior 2012 Impact Assessment Report. Many of these measures are also included in incentive programs that link payment to quality performance.

What CMS found is that, overall, while the results in some areas are concerning, healthcare is measurably improving, and not just services provided by Medicare. Patient populations not covered by Medicare are benefiting as the quality tide rises. Here are the key takeaway points from the full Impact Assessment.

  1. Quality measurement results demonstrate significant improvement: 95% of 119 publicly reported performance rates across seven quality-reporting programs showed improvement during the 2006–2012 study period. In addition, about 35% of the 119 measures were classified as high performing, meaning that performance rates exceeding 90% were achieved in each of three years running.
  2. Race and ethnicity differences in access to care began to improve over the assessment period.
  3. Survival rates were higher and infection rates lower across provider performance on CMS measures related to heart and surgical care. It’s estimated that 7,000–10,000 lives were saved and 4,000–7,000 infections prevented through improved performance. Importantly, an overall 17% reduction in patient harm may have saved CMS an estimated $12 billion.
  4. The effects of CMS’s quality measures have a ripple effect on patients beyond the Medicare population. Over 40%of the measures used in CMS quality reporting programs include individuals using Medicaid, and over 30% include patients with other payers. CMS notes that this is the kind of public-private collaboration it is seeking to further establish and expand.
  5. CMS quality measures support the aims of the National Quality Strategy (NQS) and CMS Quality Strategy: making care safer; ensuring that each person and family are engaged; promoting effective communication and coordination of care; promoting the most effective prevention and treatment practices; working with communities to promote wide use of best practices to enable healthy living; and making quality care affordable. Although the majority of data comes from process measures, CMS is seeking to aid the NQS goals by expanding measures related to patient outcomes, patient experience of care, and cost and efficiency. CMS says it is moving toward implementation of these outcome measures across programs.

Not without a price

Despite these gains, safety net hospitals continue to be at a financial disadvantage compared to other hospitals. Safety net hospitals provide a significant level of their care to low-income, un-/under-insured and vulnerable populations — making their survival absolutely critical to healthcare access for these vulnerable patients. In addition, the patients seen by safety net hospitals tend to be more acutely ill and present with more complex medical problems.

Unfortunately, not all hospitals can cherry-pick the patients most likely to pay in full and have good outcomes — thus, safety net hospitals are more likely to see their Medicare payments reduced under value-based purchasing. This occurs even though safety net hospitals’ survival scores are comparable to that of other hospitals. One strategy would be to develop a more finely attuned algorithm that accounts for the more difficult care and populations safety-net hospitals provide.

But the key point is that, although standardization and measurement are worthy goals, the inputs used for the measurements must be good data if the healthcare system is going to see improvements that are both quantifiable and meaningful.