Secretarial Review and Publication of the Annual Report to Congress and the Secretary Submitted by the Consensus-Based Entity Regarding Performance Measurement, 53520-53545 [2015-21549]

Agencies

• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 80, Number 172 (Friday, September 4, 2015)]
[Notices]
[Pages 53520-53545]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-21549]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES


Secretarial Review and Publication of the Annual Report to 
Congress and the Secretary Submitted by the Consensus-Based Entity 
Regarding Performance Measurement

AGENCY: Office of the Secretary of Health and Human Services, HHS.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: This notice acknowledges the Secretary of the Department of 
Health and Human Services' (HHS) receipt and review of the 2015 Annual 
Report to Congress and the Secretary submitted by the consensus-based 
entity (CBE) in contract with the Secretary as mandated by section 
1890(b)(5) of the Social Security Act, which was created by section 183 
of the Medicare Improvements for Patients and Providers Act of 2008 
(MIPPA) and amended by section 3014 of the Patient Protection and 
Affordable Care Act of 2010. The statute requires the Secretary to 
review and publish the report in the Federal Register together with any 
comments of the Secretary on the report not later than six months after 
receiving the report. This notice fulfills those requirements.

FOR FURTHER INFORMATION CONTACT: Corette Byrd, (410) 786-1158.
    The order in which information is presented in this notice is as 
follows:

I. Background
II. The 2015 Annual Report to Congress and the Secretary: ``National 
Quality Forum Report of 2014 Activities to Congress and the 
Secretary of the Department of Health and Human Services''
III. Secretarial Comments on the 2015 Annual Report to Congress and 
the Secretary
IV. Future Steps
V. Collection of Information Requirements

I. Background

    In recent years we have seen significant improvements in many 
important dimensions of the quality of the nation's health care. The 
2014 National Quality and Disparities Report, published in April 2015 
by the Agency for Healthcare Research and Quality and available at 
https://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/, shows, 
for example, significant improvement in the quality of hospital care in 
2013, with an estimated 1.3 million fewer harmful conditions acquired 
by patients while in the hospital and 50,000 fewer deaths

[[Page 53521]]

occurred during hospital stays as compared to 2010. However, the Report 
also indicates that there are many challenges to improving quality in 
health care across the nation. The Report shows that many patients are 
still potentially harmed by the care they receive, and only 70 percent 
of recommended care is received by patients as assessed by a broad 
array of quality measurements. It also shows that people of low income 
and racial and ethnicity minorities often receive lesser quality health 
care.
    To address these problems, the Department of Health and Human 
Services is working to improve the nation's health care delivery system 
so that the care provided when people are ill is consistently high 
quality, and that healthy people are helped to stay healthy. Similarly, 
many States are leveraging their purchasing power to achieve these same 
ends; and in the private sector, provider organizations, accrediting 
bodies, foundations, and other non-profit organizations are working to 
target and align efforts to quicken the pace of improvement.
    An essential factor for the success of all these efforts is the 
accurate, valid, and reliable measurement of the quality (and 
efficiency) of health care. Recognizing the need for good quality 
measures, the Medicare Improvements for Patients and Providers Act of 
2008 (MIPPA) created section 1890 of the Social Security Act (the Act), 
which requires the Secretary of HHS to contract with a consensus-based 
entity (CBE) to perform multiple duties pertaining to healthcare 
performance measurement. Section 3011 of the Patient Protection and 
Affordable Care Act of 2010 (ACA) expanded the activities of the CBE in 
improving health care quality.
    In January of 2009, a competitive contract was awarded by HHS to 
the National Quality Forum (NQF) to fulfill requirements of section 
1890 of the Act. A second, multi-year contract was awarded to NQF again 
after an open competition in 2012. This contract includes the following 
duties as mandated by section 1890(b) of the Act:
    Priority Setting Process: Formulation of a National Strategy and 
Priorities for Health Care Performance Measurement. The CBE is to 
synthesize evidence and convene key stakeholders to make 
recommendations on an integrated national strategy and priorities for 
health care performance measurement in all applicable settings. In 
doing so, the CBE is to give priority to measures that: (a) Address the 
health care provided to patients with prevalent, high-cost chronic 
diseases; (b) have the greatest potential for improving quality, 
efficiency and patient-centered health care; and (c) may be implemented 
rapidly due to existing evidence, standards of care or other reasons. 
Additionally, the CBE must take into account measures that: (a) May 
assist consumers and patients in making informed health care decisions; 
(b) address health disparities across groups and areas; and (c) address 
the continuum of care across multiple providers, practitioners and 
settings.
    Endorsement of Measures: The CBE is to provide for the endorsement 
of standardized health care performance measures. This process must 
consider whether measures are evidence-based, reliable, valid, 
verifiable, relevant to enhanced health outcomes, actionable at the 
caregiver level, feasible to collect and report, responsive to 
variations in patient characteristics such as health status, language 
capabilities, race or ethnicity, and income level and are consistent 
across types of health care providers including hospitals and 
physicians.
    Maintenance of CBE Endorsed Measures. The CBE is required to 
establish and implement a process to ensure that endorsed measures are 
updated (or retired if obsolete) as new evidence is developed.
    Review and Endorsement of an Episode Grouper Under the Physician 
Feedback Program. ``Episode-based'' performance measurement is an 
approach to better understanding the utilization and costs associated 
with a certain condition by grouping together all the care related to 
that condition. ``Episode groupers'' are software tools that combine 
data to assess such condition-specific utilization and costs over a 
defined period of time. The CBE is required to provide for the review, 
and as appropriate, endorsement of an episode grouper as developed by 
the Secretary.
    Convening Multi-Stakeholder Groups. The CBE must convene multi-
stakeholder groups to provide input on: (1) The selection of certain 
categories of quality and efficiency measures, from among such measures 
that have been endorsed by the entity; and such measures that have not 
been considered for endorsement by such entity but are used or proposed 
to be used by the Secretary for the collection or reporting of quality 
and efficiency measures; and (2) national priorities for improvement in 
population health and in the delivery of health care services for 
consideration under the national strategy. The CBE provides input on 
measures for use in certain specific Medicare programs, for use in 
programs that report performance information to the public, and for use 
in health care programs that are not included under the Social Security 
Act. The multi-stakeholder groups provide input on measures to be 
implemented through the federal rulemaking process for various federal 
health care quality reporting and quality improvement programs 
including those that address certain Medicare services provided through 
hospices, hospital inpatient and outpatient facilities, physician 
offices, cancer hospitals, end stage renal disease (ESRD) facilities, 
inpatient rehabilitation facilities, long-term care hospitals, 
psychiatric hospitals, and home health care programs.
    Transmission of Multi-Stakeholder Input. Not later than February 1 
of each year, the CBE is to transmit to the Secretary the input of 
multi-stakeholder groups.
    Annual Report to Congress and the Secretary. Not later than March 1 
of each year the CBE is required to submit to Congress and the 
Secretary of HHS an annual report. The report is to describe:
    (i) The implementation of quality and efficiency measurement 
initiatives and the coordination of such initiatives with quality and 
efficiency initiatives implemented by other payers;
    (ii) recommendations on an integrated national strategy and 
priorities for health care performance measurement;
    (iii) performance of the CBE's duties required under its contract 
with HHS;
    (iv) gaps in endorsed quality and efficiency measures, including 
measures that are within priority areas identified by the Secretary 
under the national strategy established under section 399HH of the 
Public Health Service Act (National Quality Strategy), and where 
quality and efficiency measures are unavailable or inadequate to 
identify or address such gaps;
    (v) areas in which evidence is insufficient to support endorsement 
of quality and efficiency measures in priority areas identified by the 
Secretary under the National Quality Strategy, and where targeted 
research may address such gaps; and
    (vi) the convening of multi-stakeholder groups to provide input on: 
(1) The selection of quality and efficiency measures from among such 
measures that have been endorsed by the CBE and such measures that have 
not been considered for endorsement by the CBE but are used or proposed 
to be used by the Secretary for the collection or reporting of quality 
and efficiency measures; and (2) national priorities for improvement in 
population health and the delivery of health care services for 
consideration under the National Quality Strategy.

[[Page 53522]]

    The statutory requirements for the CBE to annually report to 
Congress and the Secretary of HHS also specify that the Secretary of 
HHS must review and publish the CBE's annual report in the Federal 
Register, together with any comments of the Secretary on the report, 
not later than six months after receiving it.
    This Federal Register notice complies with the statutory 
requirement for Secretarial review and publication of the CBE's annual 
report. NQF submitted a report on its 2014 activities to the Secretary 
on February 25, 2015. This 2015 annual report to Congress and the 
Secretary of the Department of Health and Human Services (dated March 
1, 2015) is presented below in Section II. Comments of the Secretary on 
this report are presented below in section III.

II. The 2015 Annual Report to Congress and the Secretary: ``NQF Report 
of 2014 Activities to Congress and the Secretary of the Department of 
Health and Human Services''

NQF Report on 2014 Activities to Congress and the Secretary of the 
Department of Health and Human Services

I. Executive Summary
    Over the last seven years, Congress has passed two statutes with 
several extensions that call upon the Department of Health and Human 
Services (HHS) to work with a consensus-based entity (the ``Entity'') 
to facilitate multistakeholder input into (1) setting national 
priorities for improvement in population health and quality, and (2) 
recommending use of quality and efficiency measures. The first of these 
statutes is the 2008 Medicare Improvements for Patients and Providers 
Act (MIPPA) (PL 110-275), which established the responsibilities of the 
consensus-based entity by creating section 1890 of the Social Security 
Act. The second statute is the 2010 Patient Protection and Affordable 
Care Act (ACA) (PL 111-148), which modified and added to the consensus-
based entity's responsibilities. The American Taxpayer Relief Act of 
2012 (PL 112-240) extended funding under the MIPPA statute to the 
consensus-based entity through fiscal year 2013. The Protecting Access 
to Medicare Act of 2014 (PL113-93) extended funding under the MIPPA and 
ACA statutes to the consensus-based entity through March 31, 2015. HHS 
has awarded contracts to the consensus-based entity identified in the 
statute which is currently the National Quality Forum (NQF).
    These laws specifically charge the Entity to report annually on its 
work:
    As amended by the above laws, the Social Security Act (the Act)--
specifically section 1890(b)(5)(A)--also mandates that the entity 
report to Congress and the Secretary of HHS no later than March 1st of 
each year. The report must include descriptions of: (1) How NQF has 
implemented quality and efficiency measurement initiatives under the 
Act and coordinated these initiatives with those implemented by other 
payers; (2) NQF's recommendations with respect to activities conducted 
under the Act; (3) NQF's performance of the duties required under its 
contract with HHS; (4) gaps in endorsed quality and efficiency 
measures, including measures that are within priority areas identified 
by the Secretary under HHS' National Quality Strategy; (5) areas in 
which evidence is insufficient to support endorsement of quality and 
efficiency measures in priority areas identified by the National 
Quality Strategy, and where targeted research may address such gaps; 
and (6) the matters described in clauses (i) and (ii) of paragraph 
(7)(A) of section 1890(b).\1\
    This sixth Annual Report highlights NQF's work conducted between 
January 1, 2014 and December 31, 2014 related to these statutes and 
conducted under contract with HHS. The deliverables produced under 
contract in 2014 are referenced throughout this report, and a full list 
is included in Appendix A.
    In addition to NQF's statutorily mandated work, NQF worked with 
federal partners such as the Centers for Medicare & Medicaid Services 
(CMS) and the Office of the National Coordinator for Health Information 
Technology (ONC) in 2014 on a lean improvement project in order to 
streamline its endorsement processes. Also in 2014, NQF began to work 
with CMS and private insurers to further the uniform use of measures 
(commonly referred to as alignment) between the public and private 
sectors. Both of these initiatives were funded by NQF without the 
support of federal funds.
Recommendations on the National Quality Strategy and Priorities
    Section 1890(b)(1) of the Social Security Act (the Act), mandates 
that the consensus-based entity (CBE) also required under section 1890 
of the Act shall ``synthesize evidence and convene key stakeholders to 
make recommendations . . . on an integrated national strategy and 
priorities for healthcare performance measurement in all applicable 
settings.'' In making such recommendations, the entity shall ensure 
that priority is given to measures that address the healthcare provided 
to patients with prevalent, high-cost chronic diseases, that focus on 
the greatest potential for improving the quality, efficiency, and 
patient-centeredness of healthcare, and that may be implemented rapidly 
due to existing evidence and standards of care, or other reasons. In 
addition, the entity will take into account measures that may assist 
consumers and patients in making informed healthcare decisions, address 
health disparities across groups and areas, and address the continuum 
of care a patient receives, including services furnished by multiple 
healthcare providers or practitioners and across multiple settings.
    In 2010, at the request of the Department of Health and Human 
Services (HHS), the NQF-convened National Priorities Partnership (NPP) 
provided input that helped shape the initial version of the National 
Quality Strategy (NQS).\2\ The NQS was released in March 2011, setting 
forth a cohesive roadmap for achieving better, more affordable care, 
and better health. Upon the release of the NQS, HHS accentuated the 
word `national' in its title, emphasizing that healthcare stakeholders 
across the country, both public and private, all play a role in making 
the NQS a success.
    NQF has continued to further the NQS by convening diverse 
stakeholder groups to reach consensus on key strategies for 
improvement. In 2014, NQF completed work in several emerging areas of 
importance that address the National Quality Strategy, such as how to 
improve population health within communities; how to organize measures 
and other meaningful information to help consumers make informed 
healthcare decisions in the federal exchange marketplace; and how to 
dramatically improve patient safety in high-priority areas such as 
maternity care, avoidable readmissions, and patient- and family-
centered engagement. NQF also continued its work in support of the 
Common Formats, which helps standardize electronic reporting of patient 
safety event data.
Quality and Efficiency Measurement Initiatives (Performance Measures)
    Under section 1890(b)(2) and (3) of the Act, the entity must 
provide for the endorsement of standardized healthcare performance 
measures. The endorsement process shall consider whether measures are 
evidence-based, reliable, valid, verifiable, relevant to enhanced 
health outcomes, actionable at the caregiver level, feasible for 
collecting and reporting data, responsive to variations in patient

[[Page 53523]]

characteristics, and consistent across healthcare providers. In 
addition, the entity must maintain endorsed measures, including 
updating endorsed measures or retiring obsolete measures as new 
evidence is developed.
    Since its inception in 1999, NQF has developed a portfolio that 
covers many aspects of measurement and currently contains approximately 
600 measures which are in widespread use across an array of settings. 
About 300 NQF-endorsed measures are used in more than 20 federal public 
reporting and pay-for-performance programs; these and other measures 
are also used in private sector and state programs.
    Over the past several years, NQF in partnership with HHS and 
private-sector stakeholders has worked to evolve the science of 
performance measurement. This effort has included placing greater 
emphasis on both evidence behind a measure and ensuring a clear link to 
outcomes; a focus on addressing key measurement gaps, including 
measures related to care coordination and patient experience; and 
implementation of a requirement that testing of measures demonstrate 
their reliability and validity. In addition, NQF has moved from 
convening experts for the duration of a project to using standing 
committees to be able to respond in real time to newly published 
research to ensure its endorsed measures are accurate, evidence-based, 
and meaningful.
    NQF also has laid the foundation for the next generation of 
measures by providing guidance on criteria to evaluate episode 
groupers, as well as how and when to incorporate socioeconomic (SES) 
and sociodemographic factors in measurement. Beginning in January 2015, 
NQF will undertake a two year trial period during which measure 
developers will be invited to submit measures that take into account 
socioeconomic and sociodemographic factors where appropriate. These 
measures would be eligible for NQF endorsement and are required to 
include the non-risk-adjusted, stratified, and socioeconomically 
adjusted measures. This trial period will enable the field to compare 
measures which are adjusted and not adjusted for SES and to consider 
the implications of adjustment. When the trial period is over, NQF will 
determine if its endorsement criteria should be permanently changed to 
include SES adjustment where appropriate.
    Across six HHS-funded projects in 2014, NQF added 98 measures to 
its portfolio. Forty-eight of these measures were new measure 
submissions, and 50 were measures that retained their NQF endorsement. 
Twenty-seven of the 98 endorsed measures are outcome measures, 59 are 
process measures, 7 are composite measures, 2 are structural measures, 
and 3 are cost and resource use measures.
    In 2014, NQF endorsed measures in order to:
    Drive the system to be more responsive to patient/family needs--In 
2014, this effort included Person- and Family-Centered Care and Care 
Coordination endorsement projects, including patient-reported outcomes 
and patient experience surveys. These measures are used in programs 
such as the Hospital Inpatient Quality Reporting (IQR) Program and 
Physician Quality Reporting System (PQRS) and are also reported on the 
Hospital Compare Web site.
    Improve care for highly prevalent conditions--NQF's work included 
Cardiovascular, Endocrine, and Musculoskeletal endorsement projects in 
2014. NQF-endorsed measures in these areas are used in the Hospital IQR 
Program and PQRS.
    Emphasize cross-cutting areas to foster better care and 
coordination--In 2014, this effort included Behavioral Health and 
Patient Safety endorsement projects. NQF-endorsed measures in these 
areas are used in the Home Health Quality Reporting Program, Hospital 
IQR Program, the Inpatient Psychiatric Facility Quality Reporting 
Program, and PQRS.
    Support new accountability efforts coming online--NQF's work 
included Cost/Resource Use and Readmission endorsement projects. For 
example, the NQF-endorsed readmissions measures are used in CMS' 
Hospital Readmissions Reduction Program and Physician Value-Based 
Payment Modifier Program.
    During 2014, NQF also removed 93 measures from its portfolio for a 
variety of reasons: Measures no longer met endorsement criteria; 
measures were harmonized with other similar, competing measures; 
measure developers chose to retire measures they no longer wished to 
maintain; a better, substitute measure was submitted; or measures 
``topped out,'' with providers consistently performing at the highest 
level. Consistently culling the portfolio through these means and 
through the measure maintenance process ensures that the NQF portfolio 
is relevant to the most current practices in the field.
    In September 2014, HHS awarded NQF additional measure endorsement 
projects, addressing topics such as eye, ear, nose, and throat 
conditions; renal, surgery, and cardiovascular conditions; and patient 
safety. NQF has begun work on these projects by issuing calls for 
measures to be reviewed and considered for endorsement.
Stakeholder Recommendations on Quality and Efficiency Measures and 
National Priorities
    Under section 1890A of the Act, HHS is required to establish a pre-
rulemaking process under which a consensus-based entity (currently NQF) 
would convene multistakeholder groups to provide input to the Secretary 
on the selection of quality and efficiency measures for use in certain 
federal programs. The list of quality and efficiency measures HHS is 
considering for selection is to be publicly published no later than 
December 1 of each year. No later than February 1 of each year, the 
consensus-based entity (NQF) is to report to HHS the input of the 
multistakeholder groups, which will be considered by HHS in the 
selection of quality and efficiency measures.
    The Measure Applications Partnership (MAP) is a public-private 
partnership convened by NQF to provide input to HHS on the selection of 
performance measures for more than 20 federal public reporting and 
performance-based payment programs. MAP brings together approximately 
150 healthcare leaders and experts representing nearly 90 private-
sector organizations as well as federal liaisons from 7 different 
agencies for an intensive annual review of measures being considered by 
HHS. HHS then takes these recommendations under consideration as it 
develops and updates the regulations that govern these programs.
    In 2014, HHS requested that MAP review measures for 20 federal 
public reporting and payment programs. MAP's work fosters use of a more 
uniform set of measures across federal programs and across the public 
and private sectors. This uniformity--commonly referred to as 
alignment--helps providers better identify key areas in which to 
improve quality; reduces wasteful data collection for hospitals, 
physicians, and nurses; and helps to curb the proliferation of 
redundant measures which could confuse patients and payers.
    MAP also developed ``families of measures'' (groups of measures 
selected to work together across settings of care in pursuit of 
specific healthcare improvement goals) for the high-priority areas of 
affordability, population health, and person- and family-centered care; 
and provided input on measures for vulnerable populations, including 
Medicare-Medicaid enrollees and adults and children enrolled in 
Medicaid.

[[Page 53524]]

Gaps in Endorsed Quality and Efficiency Measures and Evidence and 
Targeted Research Needs
    Under section 1890(b)(5)(iv) of the Act, the entity is required to 
describe gaps in endorsed quality and efficiency measures, including 
measures within priority areas identified by HHS under the agency's 
National Quality Strategy, and where quality and efficiency measures 
are unavailable or inadequate to identify or address such gaps. Under 
section 1890(b)(5)(v) of the Act, the entity is also required to 
describe areas in which evidence is insufficient to support endorsement 
of quality and efficiency measures in priority areas identified by the 
Secretary under the National Quality Strategy and where targeted 
research may address such gaps.
    NQF continued in 2014 its efforts to fill measurement gaps--areas 
where there is a need for performance measures--by building on and 
supplementing the analytic work that informed previous Measure Gap 
Analysis Reports.\3\ Through both the MAP and performance measurement 
projects, NQF took initial steps to encourage gap-filling by 
identifying areas in which no adequate measures exist, offering more 
detailed suggestions for measure development, and involving measure 
developers in discussions about gaps.
    In an effort to provide more detailed recommendations in key 
measurement gap areas, HHS requested in 2013 that NQF convene 
multistakeholder committees to recommend priorities for performance 
measurement development across five topics areas that corresponded to 
important aspects of the National Quality Strategy, including:
     Adult Immunization--identifying critical areas for 
performance measurement to optimize vaccination rates and outcomes 
across adult populations;
     Alzheimer's Disease and Related Dementias--targeting a 
high-impact condition with complex medical and social implications that 
impact patients, their families, and their caregivers;
     Care Coordination--focusing on team-based care and 
coordination between providers of primary care and community-based 
services in the context of the ``health neighborhood'';
     Health Workforce--emphasizing the role of the workforce in 
prevention and care coordination, linkages between healthcare and 
community-based services, and workforce deployment; and
     Person-Centered Care and Outcomes--considering measures 
that are most important to patients--particularly patient-reported 
outcomes--and how to advance them through health information 
technology.
    Several important conclusions have been drawn from NQF's 2014 work 
in the gaps space. MAP reported in its 2014 pre-rulemaking review \4\ 
of proposed measures that the topic areas that need measures were 
largely the same as from the previous year. Those gaps are in safety, 
patient and family engagement, healthy living, care coordination, 
affordability, and prevention and treatment of leading causes of 
mortality. Measure development in these areas should be a priority. 
NQF's efforts to define in more detail measures needed in these and 
other areas may help fill these gaps in the future. NQF is also 
exploring efforts in partnering with other organizations to address 
persistent measure gaps.

II. Recommendations on the National Quality Strategy and Priorities

    Section 1890(b)(1) of the Social Security Act (the Act), mandates 
that the consensus-based entity (CBE) also required under section 1890 
of the Act shall ``synthesize evidence and convene key stakeholders to 
make recommendations . . . on an integrated national strategy and 
priorities for healthcare performance measurement in all applicable 
settings.'' In making such recommendations, the entity shall ensure 
that priority is given to measures: 1) That address the health care 
provided to patients with prevalent, high-cost chronic diseases; 2) 
with the greatest potential for improving the quality, efficiency, and 
patient-centeredness of healthcare; and 3) that may be implemented 
rapidly due to existing evidence, standards of care, or other reasons. 
In addition, the entity will take into account measures that: 1) May 
assist consumers and patients in making informed healthcare decisions; 
2) address health disparities across groups and areas; and 3) address 
the continuum of care a patient receives, including services furnished 
by multiple healthcare providers or practitioners and across multiple 
settings.
    In 2010, at the request of HHS, the NQF-convened National 
Priorities Partnership (NPP) provided input that helped shape the 
initial version of the National Quality Strategy (NQS). The NQS was 
released in March 2011, setting forth a cohesive roadmap for achieving 
better, more affordable care, and better health. Upon the release of 
the NQS, HHS accentuated the word `national' in its title, emphasizing 
that healthcare stakeholders across the country, both public and 
private, all play a role in making the NQS a success.
    NQF has continued to further the NQS by convening diverse 
stakeholder groups to reach consensus on key strategies for 
improvement. In 2014, NQF began or completed work in several emerging 
areas of importance that address the National Quality Strategy, such as 
how to improve population health within communities; providing advice 
to CMS on what information on healthcare quality is available to make 
informed healthcare coverage decisions through the Federal Health 
Insurance Marketplace; how to dramatically improve patient safety in 
high-priority areas through the use of Action Teams focusing on 
maternity care, avoidable readmissions, and patient and family 
engagement; and working with AHRQ to develop Common Formats for patient 
safety data reporting. Accomplishments in these areas in 2014 are 
described below.
Improving Population Health Within Communities
    The National Quality Strategy's population health aim focuses on:

    ``Improv[ing] the health of the U.S. population by supporting 
proven interventions to address behavioral, social, and 
environmental determinants of health in addition to delivering 
higher-quality care.''

    One of the NQS' six priorities specifically emphasizes:

    ``Working with communities to promote wide use of best practices 
to enable healthy living.''

    With the expansion of coverage due to the ACA, the federal 
government has an opportunity to meaningfully coordinate its 
improvement efforts with those of local communities in order to better 
integrate and align medical care and population health. Such efforts 
can help improve the nation's health and lower costs.
    To support these efforts, NQF is conducting a multiphase project 
focused on helping communities implement population health initiatives. 
In August 2014, NQF produced ``The Guide for Community Action'' 
handbook. With funding from HHS, NQF brought together a 
multistakeholder committee to develop this Guide through an open and 
iterative process. The Committee included population and community 
health experts, public health practitioners, healthcare providers, 
coordinators of home and community based services, consumer advocates, 
employers, and others who influence population health.
    To inform creation of the Guide, an Advisory Group consisting of a 
smaller

[[Page 53525]]

subset of the full Committee was convened to do an environmental scan 
at the start of the project. Additional input was provided by the full 
Committee, federal partners engaged in the work, and from the 
Government Task Lead (GTL) overseeing this project.
    The Guide \5\ was created to be used by anyone who wants to improve 
health across a population, whether locally, in a broader region or 
state, or even nationally. The Guide's purpose is to support 
individuals and groups working together at all levels to successfully 
promote and improve population health over time. It contains brief 
summaries of 10 elements important to consider during community-based 
efforts, along with actions to take and examples of practical 
resources, to build a coalition that can improve population health. The 
10 elements are summarized below:

------------------------------------------------------------------------
                Element                    Examples of questions to ask
------------------------------------------------------------------------
Self-assessment about readiness to       What types of assessments have
 engage in this work.                     already been done in efforts
                                          to improve the health of this
                                          population?
Leadership across the region and within  Which individuals or
 organizations.                           organizations in the region
                                          are recognized or potential
                                          leaders in population health
                                          improvement?
Organizational planning and priority-    Which organizations in the
 setting process.                         region engage in collaborative
                                          planning and priority setting
                                          to guide activities to improve
                                          health in the region?
Community health needs assessment and    Which organizations in the
 asset mapping process.                   region already conduct
                                          community health needs
                                          assessments or asset mapping
                                          regarding population health?
An agreed-upon, prioritized set of       What are the focus areas of
 health improvement activities.           existing population health
                                          improvement projects or
                                          programs, if any?
Selection and use of measures and        Which measures, metrics, or
 performance targets.                     indicators are already being
                                          used to assess population
                                          health in the region, if any?
Audience-specific strategic              What is the level of skill or
 communication.                           capability to engage in
                                          effective communication with
                                          each of the key audiences in
                                          the region?
Joint reporting on progress toward       Which organizations in the
 achieving intended results.              region publicly or privately
                                          report on progress in
                                          improving population health
Indications of scalability.............  For current or new population
                                          health work in the region,
                                          what is the potential for
                                          expansion into additional
                                          groups or other regions?
Plan for sustainability................  What new policy directions,
                                          structural changes, or
                                          specific resources in the
                                          region may be useful for
                                          sustaining population health
                                          improvement efforts over time?
------------------------------------------------------------------------

    Upon release of the Guide, NQF launched phase 2 of the project. 
During this phase, NQF began enlisting 10 communities to field test the 
Action Guide developed in phase 1 of the project. These 10 communities, 
selected in November 2014, represent a diverse set of groups, each with 
different levels of experience, varied geographic and demographic 
focus, and demonstrated involvement in or plans to establish population 
health-focused programs. The groups selected for the 18-month field 
test will be participating in a variety of activities, such as applying 
the content of the Guide to new or existing population health 
improvement projects, determining what works and what needs 
enhancement, and offering examples and ideas for revised or new content 
based on their own experiences. The selected groups also will have the 
opportunity to interact with one another and with members of the 
committee through in-person meetings and monthly conference calls.
    The 10 field testing groups include:

1. Colorado Department of Health Care Policy and Financing (HCPF), 
Denver, CO
2. Community Service Council of Tulsa, Tulsa, OK
3. Designing a Strong and Healthy NY (DASH-NY), New York, NY
4. Empire Health Foundation, Spokane, WA
5. Kanawha Coalition for Community Health Improvement, Charleston, WV
6. Mercy Medical Center and Abbe Center for Community Mental Health--A 
Community Partnership with Geneva Tower, Cedar Rapids, IA
7. Michigan Health Improvement Alliance, Central Michigan
8. Oberlin Community Services and The Institute for eHealth Equity, 
Oberlin, OH
9. Trenton Health Team, Inc., Trenton, NJ
10. The University of Chicago Medicine Population Health Management 
Transformation, Chicago, IL
Health Insurance Marketplaces Quality Rating System
    Under the statutory provision that the consensus-based entity will 
``take into account measures that may assist consumers and patients in 
making informed healthcare decisions,'' HHS directed NQF to convene 
multistakeholder groups to provide input and comment on the proposed 
quality and efficiency measures that will form a core measure set, the 
hierarchical structure, and organization of a Quality Rating System 
(QRS). The measures will help consumers select health plans through the 
new Health Insurance Marketplaces established by the Affordable Care 
Act.
    NQF's Measure Applications Partnership (MAP) carried out this 
project. MAP is made up of stakeholders from a wide array of healthcare 
sectors and 7 federal agencies, as well as 150 subject matter experts 
representing nearly 90 private-sector organizations, tasked with 
recommending measures for federal public reporting, payment, and other 
programs to enhance healthcare value.
    In the final deliverable for this project, the report titled Input 
on the Quality Rating System for Qualified Health Plans in the Health 
Insurance Marketplaces,\6\ MAP recognized that the initial 
implementation of the QRS will be limited to existing, developed 
measures at the health plan level and identified four primary steps to 
moving forward over the next five years:
     First, HHS should immediately begin to address areas that 
are important to consumers but are not represented across the existing 
measures in the QRS, specifically, out-of-pocket costs and shared 
decisionmaking.
     Second, HHS should thoroughly test all aspects of the QRS 
with diverse marketplace populations without delaying implementation 
and monitor on an ongoing basis.
     Third, HHS should include provider-level quality 
information within three years after initial

[[Page 53526]]

implementation for comprehensive support of consumer decisionmaking.
     Fourth, HHS should add functionality to the QRS within 
five years of initial implementation that allows consumers to customize 
and prioritize information to assist in their unique decisionmaking 
processes.
    MAP considered HHS' proposed measures and structure for the 
marketplace that will be implemented in 2016 within the context of the 
broader vision bulleted above. MAP supported 28 out of 42 measures 
proposed for the family core set and 19 out of 25 measures proposed for 
the child core set. Additionally, MAP conditionally supported eight 
measures for the family core set and four for the child core set, and 
did not support six measures for the family core set and two for the 
child core set. The recommended measures span a wide range of areas 
including CAHPS surveys for various topics, preventative care measures, 
resource use measures, readmissions measures, prenatal care, diabetes 
measures and other measures that address prevalent conditions. 
Recognizing that the proposed measures are limited to those currently 
available, MAP identified three measures to address gap areas, and 
prioritized gap areas for measure development. The specific measures 
proposed by HHS and MAP's recommendations are listed in Appendix G of 
the report.
Improving Patient Safety in High-Priority Areas
    NQF is leveraging its membership of over 400 organizations from 
every part of the healthcare system and its relationships with key 
stakeholders across the healthcare field to further mobilize private 
sector action in support of HHS' Partnership for Patients,\7\ an 
initiative started in spring 2011 to improve patient safety across the 
country. Specifically, in 2013 NQF formed three Action Teams--
multistakeholder teams tasked with developing and acting on specific 
goals aligned with the NQS safety priority--to address high-priority 
areas for improvement, including maternity care, patient and family 
engagement, and readmissions. This work concluded in 2014.
    The Action Teams comprised diverse national organizations that have 
members or chapters in communities across the country. Through 
coordination at the national level, Action Teams spur changes to the 
delivery system at the local level. These Teams were committed to 
specific goals, including:
     Reducing early elective deliveries (EEDs);
     Reducing readmissions for complex and vulnerable 
populations; and
     Engaging patients and families in health system 
improvement.
    The Action Teams developed Action Pathway Reports and other tools 
as resources for those who wish to learn from the challenges and 
successes of the Action Teams.
    Additionally in 2014, NQF held four quarterly meetings and 
developed four impact reports that called out innovative ideas and best 
practices that have the potential to accelerate change in the area of 
patient safety. These meetings focused on specific drivers for safety, 
including strengthening the workforce, accreditation and certification, 
purchasing and payment, and patient and family engagement. Quarterly 
impact reports provided a synopsis of Action Team and stakeholder 
activities as well as the quarterly meetings. The accomplishments of 
each of the three Action Teams are described below.
Maternity Action Team
    The Maternity Action Team was reconvened in early 2014 to continue 
its work on addressing inappropriate maternity care. Although 
significant progress has been made in reducing EEDs, there are many 
areas of the country that are still finding it difficult to achieve 
results. As described in the Action Team's report, Maternity Action 
Team Action Pathway: Promoting Healthy Mothers and Babies,\8\ the 
overarching goal of the Action Team was to reduce EEDs prior to 39 
weeks gestation to 5 percent or less in every state. To support this 
goal, three specific strategies were identified: Measurement, 
partnership, and consumer and provider engagement.
    The Action Team developed and disseminated a Playbook for the 
Successful Elimination of Early Elective Deliveries \9\ in August 2014 
to provide guidance and strategies to help those still struggling to 
reduce their rates of EEDs.
Readmissions Action Team
    The Readmissions Action Team was formed to support the Partnership 
for Patients goal of reducing hospital readmissions within 30 days by 
20 percent on a national level. As described in the Readmissions Action 
Team Action Pathway: Reducing Avoidable Admissions and Readmissions 
\10\ report, the focus of this team was to achieve the Partnership for 
Patients goals by identifying high-risk patients with psychosocial 
needs, and leveraging patient, provider, and community partnership to 
address those needs so as to prevent unwarranted readmissions. 
Strategies identified by the Action Team include working together 
across stakeholder groups to enhance systems improvement, collaboration 
among providers, and patient and family engagement. The Action Team 
shared best practices and approaches to improving the quality of care 
for high-risk populations to foster both individual and collective 
efforts to further progress.
Patient and Family Engagement Action Team
    The Patient and Family Engagement Action Team supports the 
Partnership for Patients goals around patient safety by utilizing the 
support of patients and families to be patient safety advocates, and by 
partnering with healthcare organizations to encourage person-centered 
care as an organizational core value. As described in the Team's 
Patient and Family Engagement Action Pathway: Fostering Authentic 
Partnerships between Patients, Families, and Care Teams \11\ report, 
three strategies were used to support the goal of fostering authentic 
partnerships: Identifying tools, resources, and practices that reflect 
patient-preferred practices, and encourage meaningful dialogue among 
providers; leveraging existing networks and relationships to spread 
these tools and practices; and activating patients and families to 
participate in organizational redesign and governance to drive system-
level change.
    In support of the strategy to identify tools that can foster 
dialogue between patients and caregivers, the Action Team created and 
promoted the use of a Patient Passport, a tool to assist patients in 
having meaningful and effective communication with providers, 
particularly in the hospital setting. The tool allows patients to 
initiate and guide conversations with their providers, with the added 
benefit of making frontline staff's work simpler by presenting to them 
information about the patient that is concise and meaningful.
Common Formats for Patient Safety Data
    For more than 10 years, both NQF and the Agency for Healthcare 
Research and Quality (AHRQ) have developed and promulgated standardized 
approaches for reporting and reducing adverse safety events to enable 
shared learning across the country. NQF's list of Serious Reportable 
Events (SREs), first published in 2002, has helped raise awareness and 
stimulate action around

[[Page 53527]]

preventable adverse events that should be publicly reported. The 
Patient Safety and Quality Improvement Act of 2005 advanced reporting 
further by authorizing the development of common and consistent 
definitions and standardized formats to collect, collate, and analyze 
patient safety events occurring within and across healthcare providers. 
AHRQ developed the Common Formats--a standardized method for collection 
and compilation of information about patient safety events occurring in 
the United States, including Serious Reportable Events--to help 
operationalize the Act.
    To ensure the Common Formats are feasible for use in the field, 
AHRQ has contracted with NQF to implement a process that ensures broad 
stakeholder input on new Common Formats modules developed by AHRQ for 
both hospitals and nursing homes.
    NQF has established a process and tools for receiving comments on 
the Common Formats beginning with the release of each set and version 
and continuing for a specified period thereafter. This project is 
guided by an NQF-convened Expert Panel that considers and makes 
recommendations regarding comments from healthcare stakeholders. 
Previously, based upon the Expert Panel's recommendations, NQF 
supported AHRQ in its iterative revisions and refinements of Common 
Formats for hospitals and nursing homes. AHRQ has now developed Common 
Formats for surveillance in hospitals.
    In 2014, NQF continued to collect comments on all versions of 
Common Formats for Event Reporting--Hospital, Common Formats for Event 
Reporting--Nursing Home V.0.1 Beta, and for individual modules that 
have been integrated into these sets. NQF continues to collect comments 
on Hospital V.1.1 and V.1.2 and Nursing Home V.0.1 Beta. All comments 
received in 2014 have been acted upon by the Expert Panel and 
recommendations have been provided to AHRQ. Future expansions of the 
Common Formats will include patient events in ambulatory settings.

III. Quality and Efficiency Measurement Initiatives (Performance 
Measures)

    Under section 1890(b)(2) and (3) of the Act, the entity must 
provide for the endorsement of standardized health care performance 
measures. The endorsement process shall consider whether measures are 
evidence-based, reliable, valid, verifiable, relevant to enhanced 
health outcomes, actionable at the caregiver level, feasible for 
collecting and reporting data, responsive to variations in patient 
characteristics, and consistent across types of healthcare providers. 
In addition, the entity must maintain endorsed measures by ensuring 
that such measures are updated, or retired, as new evidence is 
developed.
    Standardized healthcare performance measures are used by a range of 
healthcare stakeholders for a variety of purposes. Measures help 
clinicians, hospitals, and other providers understand whether the care 
they provide their patients is optimal and appropriate, and if not, 
where to focus their efforts to improve. In addition, performance 
measures are increasingly used in federal accountability pay for 
reporting and payment programs, to inform patient choice, and to assess 
the effects of care delivery changes.
    Working with multistakeholder committees to build consensus, NQF 
reviews and endorses healthcare performance measures. Since its 
inception in 1999, NQF has developed a portfolio of approximately 600 
NQF-endorsed measures which are in widespread use across an array of 
settings. The federal government, states, and private sector 
organizations use NQF's endorsed measures to evaluate performance and 
share information with patients and their families. Together, NQF 
measures serve to enhance healthcare value by ensuring that consistent, 
high-quality performance information and data are available, which 
allows for comparisons across providers and the ability to benchmark 
performance.
    Over the past several years, NQF, in partnership with HHS and 
others, has worked to evolve the science of performance measurement. 
This effort has included placing greater emphasis on evidence and 
requiring a clear link to outcomes; a greater focus on addressing key 
gaps in care, including care coordination and patient experience; and a 
requirement that testing of measures demonstrates their reliability and 
validity. In addition, in 2014 NQF moved to using standing committees 
to be able to respond in real time to newly published research to 
ensure its endorsed measures are accurate, evidence-based, and 
meaningful.
    In 2014, NQF also laid the foundation for the next generation of 
measures by providing guidance on how to address socioeconomic and 
sociodemographic factors related to measurement; \12\ criteria to use 
in evaluating episode groupers; \13\ and beginning a project on how to 
use measures to evaluate performance for rural and low-volume 
providers.
Current State of NQF Measures Portfolio: Responding to Evolving Needs
    Across 6 HHS-funded projects in 2014, NQF added 98 measures to its 
portfolio. This contrasts with 27 measures endorsed in 2013 across 6 
HHS-funded projects. The difference in endorsed measures between 2013 
and 2014 can be attributed to the fact that the 2013 work was primarily 
conducted within a contract that was nearing completion due to a delay 
in funding. New measure endorsement projects for 2014 were awarded 
under a new contracting vehicle implemented in September 2013.
    NQF ensures that the measure portfolio contains ``best-in-class'' 
measures across a variety of clinical and cross-cutting topic areas. 
Expert committees review both previously endorsed and new measures in a 
particular topic area to determine which measures deserve to be 
endorsed or re-endorsed because they are best-in-class. Working with 
expert multistakeholder committees,\14\ NQF undertakes actions to keep 
its endorsed measure portfolio relevant.
    During 2014, NQF also removed 93 measures from its portfolio. NQF 
removed about 90 measures from its portfolio in 2013. NQF removes 
measures for a variety of reasons including: measures no longer met 
more rigorous endorsement criteria; measures are harmonized with other 
similar, competing measures; measure developers chose to retire 
measures they no longer wish to maintain; or measures are ``topped-
out.''
    These ``topped-out'' measures are put into reserve because they 
show consistently high levels of performance and are therefore no 
longer meaningful in differentiating performance across providers This 
culling of measures ensures that time is spent measuring aspects of 
care in need of improvement rather than retaining measures related to 
areas where widespread success has already been achieved.
    While NQF pursues strategies to make its measure portfolio 
appropriately lean and responsive to real-time changes in clinical 
evidence, it also aggressively seeks measures from the field that will 
help to fill known measure gaps and to align with the NQS goals. 
Several important factors motivate NQF to expand its portfolio, 
including the need for eMeasures; measures that are applicable to 
multiple clinical specialties and settings of care; measures which 
assist in the evaluation of new payment models (e.g., bundled payment, 
Accountable Care Organizations, etc.); and the need for

[[Page 53528]]

more advanced measures that help close cross-cutting gaps in areas such 
as care coordination and patient-reported outcomes.
    Finally, NQF also works with stewards and developers who create 
measures, in order to harmonize related or near-identical measures and 
eliminate nuanced differences. Harmonization is critical to reducing 
measurement burden for providers, who may be inundated with requests to 
report near-identical measures. Successful harmonization results in 
fewer endorsed measures for providers to report and for payers and 
consumers to interpret. Where appropriate, NQF works with measure 
developers to replace existing process measures with more meaningful 
outcome measures.
Measure Endorsement Accomplishments
    As mentioned previously, NQF added 98 measures to its portfolio in 
2014. Forty-eight of these measures were new measure submissions and 50 
were measures that retained their NQF endorsement. Twenty-seven of the 
98 endorsed measures are outcome measures, 59 are process measures, 7 
are composite measures, 2 are structural measures, and 3 are cost and 
resource use measures.
    In 2014, NQF endorsed measures in order to:
    Drive the system to be more responsive to patient/family needs--In 
2014, NQF conducted work on Person- and Family-Centered Care and Care 
Coordination endorsement projects, including patient-reported outcomes 
and patient experience surveys. These measures are used in programs 
such as Hospital Inpatient Quality Reporting (IQR) Program, and the 
Physician Quality Reporting System (PQRS) as well as reported on the 
Hospital Compare Web site.
    Improve care for highly prevalent conditions--In 2014, NQF 
conducted work on Cardiovascular, Endocrine, and Musculoskeletal 
endorsement projects. NQF-endorsed measures in these areas are used in 
the Hospital IQR Program and PQRS.
    Foster better care and coordination by focusing on crosscutting 
areas--NQF also conducted work on Behavioral Health and Patient Safety 
endorsement projects in 2014. NQF-endorsed measures in these areas are 
used in the Home Health Quality Reporting Program, Hospital IQR 
Program, the Inpatient Psychiatric Facility Quality Reporting Program, 
and PQRS.
    Support new accountability efforts coming online-- In 2014, NQF 
conducted work on Cost/Resource Use and Readmission endorsement 
projects. For example, the NQF-endorsed readmissions measures are used 
in CMS' Hospital Readmissions Reduction Program and Physician Value-
Based Payment Modifier Program.
    Other project work also began in 2014 on topics such as health and 
well-being, patient safety, musculoskeletal, person- and family-
centered care, and surgery.
    Measure highlights in 2014 include the following:
    Behavioral health measures. In the United States, it is estimated 
that approximately 26.4 percent of the population suffers from a 
diagnosable mental disorder. These disorders--which can include serious 
mental illnesses, substance use disorders, and depression--are 
associated with poor health outcomes, increased costs, and premature 
death. Although general behavioral health disorders are widespread, the 
burden of serious mental illness is concentrated in about six percent 
of the population. In 2005, an estimated $113 billion was spent on 
mental health treatment in the United States. Of that amount, $22 
billion was spent on substance abuse treatment alone, making substance 
abuse one of the most costly (and treatable) illnesses in the nation. 
In 2014, phase 2 of this project was completed and phase 3 is in 
progress. During phase 2 of the project, the Behavioral Health Steering 
Committee evaluated 13 new measures and 11 measures undergoing 
maintenance review of which 20 measures were ratified for endorsement.
    In phase 3 of this project, which is currently ongoing, the 
Behavioral Health Standing Committee reviewed 13 new measures and 6 
measures undergoing maintenance review. The Committee recommended 13 
measures for endorsement (9 process measures, 3 outcome measures, and 1 
composite measure were approved); 1 measure was not recommended; and 1 
measure was deferred.
    Cost and resource use measures. To expand NQF's portfolio of 
measures that could be used to assess efficiency and contribute to an 
assessment of value, NQF has undertaken foundational work on cost and 
resource use definitions. Phases 2 and 3 of this project were conducted 
in 2014.
    Phase 2 focused on cardiovascular condition-specific measures; 
phase 3 focused on pulmonary condition-specific measures, and 
condition-specific episode based measures. The Cost and Resource Use 
Standing Committee reviewed three measures, and three were recommended 
for endorsement. In phase 2, three measures were ratified for 
endorsement; 2 out of the 3 measures received endorsement only with 
conditions. The conditions include a one-year look-back assessment of 
unintended consequences by reviewing the related data, as well as 
consideration for the SES trial period.
    In phase 3, all three recommended measures were ratified in 
December 2014 with the same conditions as the phase 2 measures: one-
year look-back assessment of unintended consequences, consideration for 
the SES trial period and attribution.
    Cardiovascular measures. Cardiovascular disease is the leading 
cause of death for men and women in the United States. It accounts for 
approximately $312.6 billion in healthcare expenditures annually. 
Coronary heart disease (CHD), the most common type, accounts for 1 of 
every 6 deaths in the United States. Hypertension--a major risk factor 
for heart disease, stroke, and kidney disease--affects 1 in 3 
Americans, with an estimated annual cost of $156 billion in medical 
costs, lost productivity, and premature deaths.
    In Phase 1 of the Cardiovascular project, the Standing Committee 
evaluated 8 new measures and 9 measures undergoing maintenance review 
against NQF's standard measure evaluation criteria. 14 (6 process 
measures, 5 outcome measures and 3 composite measures) of the 17 
measures submitted were recommended by the Committee, while 3 were not 
recommended.
    The second phase began in September 2014. Within this phase, the 
Standing Committee will provide recommendations for endorsement on 16 
measures (10 new measures and 6 measures undergoing maintenance review) 
against NQF's measure evaluation criteria. The final technical report 
for this phase will be posted on the NQF Cardiovascular phase 2 Web 
page and submitted to HHS in July 2015.
    As part of NQF's ongoing work with performance measurement for 
cardiovascular conditions, an open call for measures is now underway 
for the third phase of this project. Within this project, NQF is 
soliciting new measures and concepts on any cardiovascular condition, 
including hypertension, coronary artery disease, acute myocardial 
infarction, PCI, heart failure, atrial fibrillation, or any other heart 
disease, and any treatments, diagnostic studies, interventions, 
procedures (excluding surgical procedures), or outcomes associated with 
these conditions.
    Endocrine measures. Endocrine conditions most often result from the

[[Page 53529]]

endocrine system producing either too much or too little of a 
particular hormone. In the United States, two of the most common 
endocrine disorders are diabetes and osteoporosis. Diabetes, a group of 
diseases characterized by high blood glucose levels, affects as many as 
25.8 million Americans and ranks as the seventh leading cause of death 
in the United States. Osteoporosis, a bone disease characterized by low 
bone mass and density, affects an estimated 9 percent of U.S. adults 
age 50 and over. Many of the diabetes measures in the portfolio are 
among NQF's longest-standing measures.
    NQF selected the Endocrine measure evaluation project to pilot test 
a process improvement to allow frequent submission and evaluation of 
measures in order to help speed up the time from measure development to 
use in the field. This 22-month project will include three full 
endorsement cycles, allowing for the submission and review of both new 
and previously-endorsed measures every six months, instead of every 
three years which had been the norm. In addition, this project is one 
of the first to transition to the use of Standing Committees, meaning 
that the measure endorsement committee is able to review measures on a 
frequent basis instead of once at the start of a project as done 
previously.
    In cycle 1, the Standing Committee recommended 14 out of 15 
measures submitted for endorsement; the measures were ratified by the 
Board in 2014. In cycle 2, all six measures (all maintenance, no new 
measures were submitted) were recommended for endorsement. The measures 
were all process measures and related to diabetes and osteoporosis. All 
recommended measures were ratified in December 2014. The submission 
deadline for cycle 3 closed in December 2014; one composite measure and 
one outcome measure related to diabetes were submitted for maintenance 
review. The measures will be reviewed by the Committee in January 2015.
    Care coordination measures. Care coordination is increasingly 
recognized as fundamental to the effectiveness of healthcare systems in 
improving patient outcomes. Poorly coordinated care regularly leads to 
unnecessary suffering for patients, as well as avoidable readmissions 
and emergency department visits, increased medical errors, and higher 
costs.
    People with chronic conditions and multiple co-morbidities--and 
their families and caregivers--often find it difficult to navigate our 
already complex healthcare system. As this ever-growing population 
transitions from one care setting to another, they are more likely to 
suffer the adverse effects of poorly coordinated care. Incomplete or 
inaccurate transfer of information, poor communication, and a lack of 
follow-up can lead to poor outcomes, such as medication errors. 
Effective communication within and across the continuum of care will 
improve both quality and affordability.
    In the third phase of the Care Coordination project, the Standing 
Committee evaluated 1 new measure and 11 measures undergoing 
maintenance review. Eleven of the measures were recommended for 
endorsement by the Committee, and one was not recommended. Following 
review of the measures, the Committee recommended that a suite of seven 
measures regarding Emergency Transfer Communication be combined into 
one measure. The Board of Directors ratified the recommendations of the 
Committee in September 2014 and approved five measures (two process 
measures and three outcome measures) for endorsement.
    All-cause admissions and readmissions measures. Unnecessary 
admissions and avoidable readmissions to acute care facilities are an 
important focus for quality improvement by the healthcare system. 
Previous studies have shown that nearly 1 in 5 Medicare patients is 
readmitted to the hospital within 30 days of discharge, costing upwards 
of $426 billion annually.
    In 2014, the All-Cause Admissions and Readmissions Standing 
Committee evaluated 15 new measures and 3 measures undergoing 
maintenance review against NQF's standard evaluation criteria. Fifteen 
of the 18 measures were recommended for endorsement by the Committee. 
Seventeen of the 18 measures were recommended for endorsement and 
approved by the CSAC. All 17 measures were ratified for endorsement by 
the NQF Board but only with the following conditions: A one-year look-
back assessment of unintended consequences and consideration for the 
SES trial period.
    Health and well-being measures. Social, environmental, and 
behavioral factors can have significant negative impact on health 
outcomes and economic stability; yet only 3 percent of national health 
expenditures are spent on prevention, while 97 percent is spent on 
healthcare services. Population health includes a focus on health and 
well-being, along with disease and illness prevention and health 
promotion. Using the right measures can determine how successful 
initiatives are in reducing mortality and excess morbidity through 
prevention and wellness and help focus future work to improve 
population health in appropriate areas.
    In phase 1, the Health and Well-Being Standing Committee evaluated 
seven newly submitted measures and eight measures undergoing 
endorsement review. One measure was withdrawn from consideration at the 
request of the Committee and the developer and will be evaluated in 
Health and Well-Being phase 2. Most new measures were related to dental 
care and a breast cancer screening measure was updated to reflect 
current guidelines. The Standing Committee recommended 13 measures for 
endorsement while one measure was not recommended. The 13 measures (7 
process measures and 6 outcome measures) were ratified for endorsement 
in October 2014 and the final technical report was posted to the NQF 
Health and Well-Being phase 1 project Web page and submitted to HHS in 
December 2014.
    Phase 2 of the Health and Well-Being project launched in October 
2014. The call for measures is open until January 16, 2015. In this 
phase, seven measures are undergoing maintenance review against NQF's 
measure evaluation criteria.
    Patient safety measures. NQF has a 10-year history of focusing on 
patient safety. Through various projects, NQF has previously endorsed 
over 100 consensus standards related to patient safety. The Safe 
Practices, Serious Reportable Events (SREs), and NQF-endorsed patient 
safety measures are important tools for tracking and improving patient 
safety performance in American healthcare. However, gaps still remain 
in the measurement of patient safety. There is also a recognized need 
to expand available patient safety measures beyond the hospital setting 
and harmonize safety measures across sites and settings of care. In 
order to develop a more robust set of safety measures, NQF will be 
soliciting patient safety measures to address environment-specific 
issues with the highest potential leverage for improvement.
    In phase 1, the Patient Safety Standing Committee evaluated 4 new 
measures and 12 measures undergoing maintenance review. Eight of the 
measures (five process measures and three outcome measures) were 
recommended for endorsement by the Committee, and eight were not 
recommended. In addition, the Patient Safety Standing Committee 
conducted an ad hoc review of measure 0500, Severe Sepsis and Septic 
Shock: Management Bundle, due to change in

[[Page 53530]]

the underlying evidence per a randomized control trial. The Committee 
recommended continued endorsement of this measure.
    NQF opened the phase 2 call for measures for Patient Safety 
measures in 2014. The Steering Committee's evaluation will take place 
in 2015.
    Musculoskeletal measures. This project focuses on both individual 
and composite measures inclusive of all aspects of musculoskeletal 
health for all populations, with an emphasis on disparate and 
vulnerable populations. Improvement efforts for musculoskeletal 
conditions include imaging for low back pain; screening, assessment, 
and therapies for rheumatoid arthritis; assessment, monitoring, and 
therapies in the treatment of gout; and timely pain management for long 
bone fracture which are consistent with the NQS triple aim and align 
with several of the NQS priorities. NQF selected the Musculoskeletal 
project as the first to pilot test the optional path of eMeasure trial 
approval, which is intended for eMeasures that are ready for 
implementation but cannot yet be adequately tested to meet NQF 
endorsement criteria. These measures are not recommended at this stage 
for use in accountability applications such as public reporting or 
payment, but they have been judged to be ready for implementation in 
real-world settings in order to generate the data required to assess 
reliability and validity. They may be considered for endorsement after 
sufficient data to assess reliability and validity testing have been 
submitted to NQF, within three years of trial approval.
    In 2014, the Musculoskeletal Standing Committee evaluated eight new 
measures and four measures undergoing maintenance review. Three 
measures were recommended for endorsement, and four measures were 
recommended for eMeasure trial approval. All recommended measures were 
process measures and related to gout and rheumatoid arthritis.
    Person- and family-centered care measures. Ensuring person- and 
family-centered care is a core concept embedded in the National Quality 
Strategy priority of ensuring that each person and family is engaged as 
partners in their care. Person- and family-centered care encompasses 
the outcomes of interest to patients receiving healthcare services, 
including health-related quality of life, functional status, symptoms 
and symptom burden, and experience with care as well as patient and 
family engagement in care, including shared decisionmaking and 
preparation and activation for self-care management. This project is 
focusing on patient-reported outcomes (PROs), but also may include some 
clinician-assessed functional status measures. NQF's 2012 project on 
PROs \15\ in performance measurement provides a basis for reviewing 
PRO-based performance measures, referred to as PRO-PMs.
    NQF has identified 40 endorsed measures that are due for 
endorsement maintenance. Given the number and complexity of endorsed 
measures to review as well as an expectation of additional new measure 
submissions, NQF will undertake this project in two phases. Phase 1 
examined experience with care measures, and phase 2 will review 
measures of functional status (clinician and patient-assessed).
    In phase 1, the Standing Committee evaluated one new measure and 11 
measures undergoing maintenance review. The Committee recommended 10 
measures for endorsement; one measure was not recommended and one 
measure was withdrawn by the developer. The 10 recommended measures 
(all outcome measures) were ratified for endorsement in December 2014.
    The second phase began in September 2014, and a total of 28 
measures (14 new measures and 14 measures undergoing maintenance 
review) will be reviewed and evaluated. The majority of phase 2 
measures are outcome measures with the exception of four process 
measures.
    Surgery measures. The rate of surgical procedures is increasing 
annually. In 2010, 51.4 million inpatient surgeries were performed in 
the United States; 53.3 million procedures were performed in ambulatory 
surgery centers. Ambulatory surgery centers have been the fastest 
growing provider type participating in Medicare. As part of NQF's 
ongoing work with performance measurement for patients undergoing 
surgery, this project seeks to identify and endorse performance 
measures that address a number of surgical areas, including cardiac, 
thoracic, vascular, orthopedic, neurosurgery, urologic, and general 
surgery. This project will seek new performance measures in addition to 
conducting maintenance reviews of surgical measures endorsed prior to 
2012 using the most recent NQF measure evaluation criteria.
    In 2014, the Surgery Standing Committee evaluated 9 new measures 
and 20 measures undergoing maintenance review in phase 1. Twenty-one of 
these measures (10 outcome measures, 6 outcome measures, 2 composite 
measures, and 3 structural measures) were recommended (9 recommended 
for reserve status) for endorsement by the Committee, 7 were not 
recommended, and 1 was withdrawn by the developer.
    Phase 2 of this project builds on the work of the previous Surgery 
Endorsement project, launched in 2013. Phase 2 will seek to identify 
and endorse new measures that can be used to assess surgical conditions 
at any level of analysis or setting of care, and review endorsed 
measures scheduled for maintenance. The call for measures under phase 2 
was initiated in 2014 and closed on January 14, 2015. A total of 26 
measures will undergo maintenance review in this phase.
    Eye care and ear, nose, and throat conditions measures. This 
project seeks to identify and endorse performance measures for 
accountability that address eye care and ear, nose, and throat health. 
Nineteen measures will undergo maintenance review using NQF's measure 
evaluation criteria in the areas of glaucoma, macular degeneration, 
hearing screening and evaluation, and ear infections. NQF initiated the 
call for measures in 2014.
    Renal measures. Renal disease is a leading cause of morbidity and 
mortality in the United States. This project will identify and endorse 
performance measures for accountability and quality improvement for 
renal conditions. Specifically, the work will examine measures that 
address conditions, treatments, interventions, or procedures relating 
to end-stage renal disease (ESRD), chronic kidney disease (CKD) and 
other renal conditions. Measures that address outcomes, treatments, 
diagnostic studies, interventions, and procedures associated with these 
conditions will be considered. In addition, 21 measures will undergo 
maintenance review using NQF's measure evaluation criteria. NQF opened 
a call for measures in 2014; it will remain open until February 27, 
2015.
Advancing Measurement Science
    In 2014, NQF was again asked to provide guidance on emerging areas 
of importance by bringing together experts and diverse stakeholders to 
achieve consensus on next steps in deciding whether or not it is 
appropriate to risk adjust measures for socioeconomic and 
sociodemographic factors and how to best define and construct episode 
groupers. The reports--Risk Adjustment for Socioeconomic Status or 
Other Sociodemographic Factors \16\ and Evaluating Episode Groupers: A 
Report from the National Quality Forum,\17\ were completed to help 
advance the science of performance measurement.

[[Page 53531]]

    Risk Adjustment for Socioeconomic Status or other Sociodemographic 
Factors. With funding from HHS, NQF convened an Expert Panel tasked 
with considering whether to adjust performance measures for 
socioeconomic status (SES) and other demographic factors, including 
income, education, primary language, health literacy, race, and other 
factors. The Panel's report, released in August, has several major 
implications for NQF policy and the field of measurement.
    Whether to adjust measures for SES and sociodemographic factors is 
of high interest to stakeholders who have passionate views and concerns 
on all sides of the issue. As a testament to these concerns, NQF 
received more public comments on this topic than any other project to 
date. All stakeholders expressed a need for performance measures to 
provide fair comparisons across those being measured, and also agreed 
that disparities in healthcare and health faced by disadvantaged 
patients should not be hidden. In addition there are major challenges 
for the providers and health plans that care for these disadvantaged 
populations that should not be ignored.
    The Expert Panel recommended that measures should be adjusted for 
socioeconomic status if certain conditions are met. The panel further 
recommended that if a measure is adjusted for SES factors, the 
performance data must be stratified so that any disparities are made 
visible. The panel also made specific recommendations for 
operationalizing potential SES and sociodemographic adjustment, 
including guidelines for selecting risk factors and the kind of 
information to submit for measure review. Finally, the Panel 
recommended that NQF appoint a standing Disparities Committee which 
will ensure consistency in applying standards for SES adjusted measures 
and study whether or not there were unintended consequences when using 
such measures in the field.
    Moving forward, NQF has accepted the recommendations of the Panel 
and will begin a two-year trial period in 2015 during which the 
previous NQF restriction against SES risk adjustment will be lifted.
    Committees evaluating measures will be able to recommend that a 
measure be risk adjusted for socioeconomic or sociodemographic factors 
only if certain conditions are met. After the trial period concludes, 
NQF will determine if its criteria should be permanently changed to 
include SES adjustment under certain circumstances. In addition, work 
has begun to seat the new standing Disparities Committee. Additional 
details describing the trial period will be posted on the NQF Web site 
as they become available.
    Episode Grouper Criteria. Episode-based performance measurement is 
one approach to better understanding the utilization and costs 
associated with certain conditions by grouping care into condition-
specific or procedure-specific episodes. Episode grouper software tools 
are an accepted method for aggregating claims data into episodes to 
assess condition-specific utilization and costs. Using an episode 
grouper, healthcare services provided over a defined period of time can 
be analyzed and grouped by specific clinical conditions to generate an 
overall picture of the services used to manage that condition.
    Section 3003 of the Patient Protection and Affordable Care Act 
(Affordable Care Act) Pub. L. 111-148, requires the Secretary of HHS to 
develop an episode grouper. With funding from HHS, NQF convened an 
Expert Panel to define the characteristics and challenges of 
constructing episode groupers; determine an initial set of criteria by 
which episode groupers could be evaluated; and identify implications 
and considerations for NQF endorsement of episode groupers. The panel 
did not focus on a particular grouper or product, but instead 
recommended criteria that can be applied to any episode grouper that 
may be submitted for evaluation.
    The panel recommended the following submission items for 
evaluation: descriptive information on the intent and planned use of 
the grouper; the clinical logic and data required for grouping claims; 
and reliability and validity testing. In particular, the panel 
emphasized the importance of understanding the intent and planned use 
for evaluating potential threats to validity and possible unintended 
consequences of using the grouper.
    Further input from NQF's Consensus Standards Approval Committee 
(CSAC) confirmed the complexity of issues regarding the evaluation of 
episode groupers. CSAC suggested that endorsement for episode groupers 
is premature, however, and acknowledged there is a need for: (1) A 
qualitative peer review process to initially evaluate episode groupers, 
and (2) a process to facilitate transparency for stakeholders about 
what is contained within episode groups. The framework outlined in the 
NQF report \18\ addresses these needs and moves the field forward to 
eventual evaluation and endorsement of episode groupers.
    The Panel also generally agreed that evaluation of the CMS public 
episode grouper would be a suitable starting point to learn and 
understand the feasibility of applying the approaches and criteria 
outlined in this report. In order to fully implement this process, 
additional work would be needed to refine the criteria and submission 
elements and build out a process for evaluation. Taking into account 
NQF's expertise, further efforts to explore groupers should focus on 
how the measures developed from an episode grouper can be evaluated and 
endorsed.
New Work Ahead
    Since September 2014, HHS has awarded to NQF several additional 
endorsement projects as well as new conceptual work related to the use 
of HIT to further performance measurement, and work to develop 
measurement frameworks for both rural areas and home- and community-
based services. The new endorsement work focuses on eye, ear, nose, and 
throat conditions, and renal care. NQF has begun these projects, as 
well as issuing calls for measures to be reviewed by expert panels and 
considered for endorsement.
Work Related to Facilitating eMeasurement
    Implementation and adoption of health information technology (HIT) 
is widely viewed as essential to the transformation of healthcare. 
While the use of HIT presents many new opportunities to improve patient 
care and safety, it can also create new hazards, and will fulfill its 
potential only if the risks associated with its use are identified and 
a coordinated effort is developed to mitigate those risks.
    An HIT-related safety event--sometimes called ``e-iatrogenesis''--
has been defined as ``patient harm caused at least in part by the 
application of health information technology.'' \19\ Detecting and 
preventing HIT-related safety events is challenging, because these are 
often multifaceted events, involving not only potentially unsafe 
technological features of electronic health records, for example, but 
also user behaviors, organizational characteristics, and rules and 
regulations that guide most technology-focused activities.
    This project will be guided by a multistakeholder NQF Committee 
which includes experts in health information technology data systems 
and electronic health records, providers across different settings, 
front-line clinicians, public and private payers, and experts in 
patient safety issues related to the use of HIT. The

[[Page 53532]]

Committee will work to explore the intersection of HIT and patient 
safety in order to create a report that will provide a comprehensive 
framework for assessment of HIT safety measurement efforts, a measure 
gap analysis and recommendations for gap-filling, and best practices 
and challenges in measurement of HIT safety issues to-date. In 2014, 
NQF released a call for nominations and finalized the standing 
committee for this project.
    In addition, NQF was awarded a project on value sets in late 2014 
that will begin in 2015.

IV. Stakeholder Recommendations on Quality and Efficiency Measures and 
National Priorities

Measure Applications Partnership
    Under section 1890A of the Act, HHS is required to establish a pre-
rulemaking process under which a consensus-based entity (currently NQF) 
would convene multistakeholder groups to provide input to the Secretary 
on the selection of quality and efficiency measures for use in certain 
federal programs. The list of quality and efficiency measures HHS is 
considering for selection is to be publicly published no later than 
December 1 of each year. No later than February 1 of each year, the 
consensus-based entity is to report the input of the multistakeholder 
groups, which will be considered by HHS in the selection of quality and 
efficiency measures.
    The Measure Applications Partnership (MAP) is a public-private 
partnership convened by NQF, as mandated by the ACA (Pub. L. 111-148, 
section 3014). MAP was created to provide input to HHS on the selection 
of performance measures for more than 20 federal public reporting and 
performance-based payment programs. Launched in the spring of 2011, MAP 
is composed of representatives from more than 90 major private-sector 
stakeholder organizations, 7 federal agencies, and approximately 150 
individual technical experts. For detailed information regarding the 
MAP representatives, criteria for selection to MAP and length of 
service, please see Appendix D.
    MAP provides a forum to get the private and public sectors on the 
same page with respect to use of measures to enhance healthcare value. 
In addition, MAP serves as an interactive and inclusive vehicle by 
which the federal government can solicit critical feedback from 
stakeholders regarding measures used in federal public reporting and 
payment programs. This approach augments CMS' traditional rulemaking, 
allowing the opportunity for substantive input to HHS in advance of 
rules being issued. Additionally, MAP provides a unique opportunity for 
public- and private-sector leaders to develop and then broadly review 
and comment on a future-focused performance measurement strategy, as 
well as provide shorter-term recommendations for that strategy on an 
annual basis. MAP strives to offer recommendations that apply to and 
are coordinated across settings of care; federal, state, and private 
programs; levels of attribution and measurement analysis; payer type; 
and points in time.
    In 2014, the MAP took on several diverse tasks focused on 
recommending measures for federal public reporting and payment 
programs; developing ``families of measures'' (groups of measures 
selected to work together across settings of care in pursuit of 
specific healthcare improvement goals); and providing input on measures 
for vulnerable populations, including Medicare-Medicaid enrollees and 
adults and children enrolled in Medicaid.
2014 Pre-Rulemaking Input
    On December 1, 2013, MAP received and began reviewing a list of 234 
measures under consideration by HHS for use in more than 20 Medicare 
programs covering clinician, hospital, and post-acute care/long-term 
care settings. The MAP Pre-Rulemaking Report: 2014 Recommendations on 
Measures Under Consideration by HHS \20\ represents the MAP's third 
annual round of input regarding performance measures under 
consideration for use in federal programs.
    In this pre-rulemaking report issued in 2014, MAP recommended that 
HHS include 216 measures in different Medicare programs. As MAP 
supported some measures for use in multiple programs, this equaled 115 
unique measures. Further, MAP recommended that HHS remove 48 measures 
from the programs. To sharpen its feedback, MAP provided new 
descriptions for its recommendations. Starting this year, it initiated 
the term ``conditional support'' in order to define explicit conditions 
that must be resolved before a measure receives MAP's full support for 
implementation. This designation, which replaces the previous option of 
``supporting the direction'' of a measure, provides a clearer pathway 
for getting the measure into use.
    MAP enhanced its 2014 pre-rulemaking process by utilizing the 
following approach (also contained in Appendix C of the pre-rulemaking 
report):
     MAP's deliberations were informed by its prior work, 
including its 2012 and 2013 pre-rulemaking reports, families of 
measures, and measure gaps previously identified across all MAP 
reports.
     MAP used its Measure Selection Criteria to evaluate 
existing measures in use by programs before receiving the new measures 
under consideration to help make meetings more efficient.
     Building upon its program measure set evaluations, MAP 
determined whether the measures on HHS' list of measures under 
consideration would enhance the program measure sets and provided 
rationales for its recommendations.
     Finally, after reviewing the measures under consideration, 
MAP reassessed the program measure sets for remaining high-priority 
gaps.
    In its 2014 pre-rulemaking report, MAP noted some progress towards 
both measurement alignment--uniform use of measures across federal 
programs--and filling of measure gaps. In terms of measure alignment, 
MAP found that a majority of measures are being used in more than one 
HHS program. While this is promising, MAP noted the need to make 
further progress in using similar measures across a variety of public- 
and private-sector initiatives. In terms of measure gaps, MAP found 
similarly mixed results. Although there are now measures deployed to 
address areas in which there had previously been no meaningful way to 
measure performance, multiple gaps remain. These gaps include critical 
hospital safety measure gaps in the Inpatient Hospital Quality 
Reporting, Hospital Value-Based Purchasing, and Hospital Acquired 
Conditions Reduction Programs and clinician outcome measures for the 
Value-Based Payment Modifier and Physician Compare. MAP members have 
noted that they would like to see a more systematic assessment of 
ongoing progress towards gap-filling going forward.
2015 Pre-Rulemaking Input
    In 2014, the MAP also began work on the 2015 Pre-Rulemaking Report. 
The four MAP workgroups--Clinician, Dual Eligible Beneficiaries, 
Hospital, and Post-Acute Care/Long-Term Care--met individually in 
December to review and provide input to the MAP Coordinating Committee 
on measure sets for use in federal programs addressing their respective 
populations. A report detailing recommended measures will be released 
on February 1, 2015. In addition, two topical pre-rulemaking reports 
will be issued in 2015, one on hospital and PAC/LTC programs (February 
15, 2015) and another on clinician programs and cross-cutting measures 
(March 15, 2015).

[[Page 53533]]

Families of Measures: Affordability, Person- and Family-Centered Care, 
and Population Health
    In 2014, HHS again tasked the MAP to identify new families of 
measures--groups of measures selected to work together across settings 
of care in pursuit of specific healthcare improvement goals--in three 
high-priority areas that relate to NQS priorities: Affordability, 
person- and family-centered care, and population health. In July 2014, 
the MAP Task Forces for the Affordability, Person- and Family-Centered 
Care, and Population Health topics released a final report, Finding 
Common Ground for Healthcare Priorities: Families of Measures for 
Assessing Affordability, Population Health, and Person-and Family-
Centered Care.\21\
    There were several cross-cutting issues that emerged across these 
three families of measures. First, measures need to be aligned with 
important concept areas, such as the aims of the NQS. Second, families 
of measures provide a tool that stakeholders can use to identify the 
most relevant available measures for particular measurement needs, 
promoting alignment by highlighting important measurement categories 
that can be applied to other measurement initiatives. And finally, 
while families include important current measures, there are not 
sufficient measures for assessing several priority areas within each 
family. This finding highlights the need for further development of 
measures in affordability, population health, and person- and family-
centered care.
Affordability Family of Measures
    Measurement plays a critical role in improving affordability. 
Rising healthcare costs are affecting all stakeholders, and all 
stakeholders have a shared responsibility for making care affordable. 
In order to help address this issue, MAP and NQF staff went through a 
multistage process to identify the most promising affordability 
measures to constitute a family of related measures. These measures 
were identified and selected based on evidence of impact, such as the 
leading causes of preventable death or the conditions associated with 
highest healthcare spending. Measures were then separated into two 
overarching categories, measures of current spending, and measures of 
cost drivers. A chart detailing the framework and measures identified 
for the Affordability Family are included in Appendix C of the 
report,\22\ Finding Common Ground for Healthcare Priorities: Families 
of Measures for Assessing Affordability, Population Health, and Person- 
and Family-Centered Care.
    On a broader level, MAP pointed out that the current United States 
health system is opaque in terms of price and cost. This lack of 
transparency is a challenge for patients who cannot find out in advance 
what any given healthcare service will cost. In addition, to fully 
understand efficiency and value, cost measures must be considered in 
conjunction with measures of quality. This would allow consumers to 
understand trade-offs between cost and quality and would allow the user 
to identify when cost can be reduced while maintaining or improving 
quality.
    MAP also noted that current measures are limited in their ability 
to describe the full cost picture. In addition, MAP highlighted that 
there are direct and indirect costs from disease and treatment, and 
that current measures focus on direct costs while excluding indirect 
costs that may be significant for patients and families, e.g., 
transportation to providers, lost income from missing work. An 
additional challenge is the limited number of composite measures that 
provide high-level information to consumers, payers, and purchasers and 
give them a big picture idea of affordability. Further work is needed 
to produce measures that comprehensively capture cost at multiple 
levels.
Population Health Family of Measures
    Measuring the upstream determinants of health, both in healthcare 
and community settings, is critical for improving population health. 
Although it is important to focus on the health of the entire 
population, attention should also be given to health disparities and 
the unique needs of subpopulations. Focusing on interventions that both 
improve the health of people in geographic or geopolitical areas as 
well as population-based outcomes will help achieve the goals of the 
NQS. For the Population Health Family of Measures, MAP selected 
measures of clinical preventive services, such as screenings and 
immunizations, as well as a number of measures that address topics 
outside of the traditional healthcare system. In addition, MAP 
considered how measures could be used in applications such as a 
community health needs assessment and public health activities. This 
approach coincides with efforts to redirect focus from individual sick 
care to the health and well-being of populations.
    MAP selected a family of population health measures based on an 
overarching framework and broad measurement domains which included 
consideration for measures of total population health, determinants of 
health, and health improvement activities. MAP refined this conceptual 
framework to identify topic areas that address key aspects of 
population health, with the final groupings largely aligning with the 
Healthy People 2020 Leading Health Indicator topic areas. A chart 
detailing the framework and measures identified for the Affordability 
Family are included in Appendix D of the report,\23\ Finding Common 
Ground for Healthcare Priorities: Assessing Affordability, Population 
Health, and Person- and Family-Centered Care.
Person- and Family-Centered Care Family of Measures
    Collaborative partnerships between persons, families, and their 
care providers are critical to enabling person- and family-centered 
care across the healthcare continuum. Family involvement has been 
correlated with improved patient and family outcomes and decreased 
healthcare costs. Given the positive impact that person- and family-
centered care can have, measurement should strive to not only capture 
patients' experience of care but also include patient-reported measures 
that evaluate meaningful outcomes for those receiving care.
    Working with a set of guiding principles for person- and family-
centered care, MAP focused on creating a family of measures that 
covered five high priority topic areas: interpersonal relationships, 
patient and family engagement, care planning and delivery, access to 
support, and quality of life. A chart detailing the high-priority topic 
areas and measures identified for the Person- and Family-Centered Care 
Family of measures is included in Appendix E of the report,\24\ Finding 
Common Ground for Healthcare Priorities: Assessing Affordability, 
Population Health, and Person- and Family-Centered Care. Also included 
under Appendix E is a crosswalk of all the pertinent CAHPS survey tools 
at the measure level to the topic areas within the family of measures.
2014 Input on Quality Measures for Dual Eligible Beneficiaries
    In support of the NQS aims to provide better, more patient-centered 
care as well as improve the health of the U.S. population through 
behavioral and social interventions, HHS asked NQF to again convene a 
multistakeholder group via MAP to address measurement issues related to 
people enrolled in both the Medicare and Medicaid programs--a 
population often referred to as the ``dual

[[Page 53534]]

eligibles'' or Medicare-Medicaid enrollees. In August 2014, MAP 
released its fifth report focused on this population: 2014 Input on 
Quality Measures for Dual Eligible Beneficiaries.\25\
    In this report, MAP provided its latest guidance to HHS on the use 
of performance measures to evaluate and improve care provided to 
Medicare-Medicaid enrollees. Building on prior work in this area, MAP:
     Updated the Family of Measures for Dual Eligible 
Beneficiaries and described persistent gaps in measures;
     Explored strategies to improve health-related quality of 
life by fostering shared accountability across providers on a given 
team; and
     Described an approach to gathering feedback from 
stakeholders across the field using measures focused on Medicare-
Medicaid enrollees to inform MAP's future decisionmaking.
    The Family of Measures for Dual Eligible Beneficiaries is a group 
of 59 total measures determined to be the best available to address the 
needs of this unique population. It was updated in 2014 with the 
removal of two measures and the addition of one measure. The measures 
MAP removed related to e-prescribing and HIV screening, and were no 
longer NQF-endorsed or being maintained by their measure stewards. 
Three newly endorsed measures were considered for inclusion into the 
Family and one measure (NQF #2158 Payment-Standardized Medicare 
Spending Per Beneficiary) was added to address the important topic of 
cost. The Family still lacks an equivalent measure of costs incurred by 
Medicaid in caring for Medicare-Medicaid enrollees.
    MAP also continued to monitor the pipeline of measures in 
development that are relevant to Medicare-Medicaid enrollees, including 
six measures NCQA is designing for use in managed long-term services 
and supports programs. Critical measure gap areas remain, including 
shared decisionmaking and psychosocial needs.
    Since the start of MAP's work, quality of life has been identified 
as a high-leverage opportunity for improvement through measurement. MAP 
discussed methods for measuring and improving quality of life outcomes 
tied to long-lasting health conditions. Specifically, MAP's report 
describes how the medical model needs to be coupled with a social 
orientation to providing care and supports. Four tactics are explored: 
person- and family-centered care, team-based approaches to care, shared 
accountability, and shared decisionmaking. MAP looked to current 
examples of how quality of life has been quantified, including 
indicators and surveys such as the CMS CARE Tool that measures 
functional status, and the National Core Indicators survey that 
evaluates quality of life aspects as reported by consumers with 
developmental disabilities.
2014 Report on the Core Set of Health Care Quality Measures for Adults 
Enrolled in Medicaid
    MAP reviewed the Core Set of Health Care Quality Measures for 
Adults Enrolled in Medicaid (Medicaid Adult Core Set) to carefully 
evaluate and identify opportunities to improve the measures in use. In 
doing so, MAP considered states' feedback from the first year of 
implementation and applied its standard Measure Selection Criteria. MAP 
supported the continued use of most measures in the Core Set to 
maintain stability for participating states. The committee recommended 
the removal of one measure (NQF #0063 Comprehensive Diabetes Care: LDL-
C Screening) because clinical guidelines underpinning it are in flux. 
Additionally, MAP requested the phased addition of up to three measures 
to the Core Set, addressing the topics of diabetes care, medication 
management for asthma, and care transitions.
    MAP recommended that HHS continue to support states' efforts to 
gather, report, and analyze data that inform quality improvement 
activities. The Medicaid core set program is still new, and uses of 
quality data are expected to gradually mature from an internal focus on 
accuracy and year-over-year improvement to a more sophisticated 
approach involving benchmarking and public reporting. At the same time, 
HHS and MAP remain conscious that states are voluntarily participating 
in submitting data on the Medicaid Adult Core Set and need to be 
mindful of that reality. The program measure set will continue to 
evolve in response to changing federal, state, and stakeholder needs 
and its maintenance should be considered a long-term strategic goal.
Strengthening the Core Set of Health Care Quality Measures for Children 
Enrolled in Medicaid and CHIP, 2014
    HHS awarded NQF additional work in 2014 to assess and strengthen 
the Core Set of Health Care Quality Measures for Children Enrolled in 
Medicaid and CHIP (Child Core Set). Using a similar approach to its 
review of the Adult Core Set, MAP performed an expedited review over a 
period of ten weeks to provide input to HHS within the 2014 federal 
fiscal year. MAP considered states' feedback from their ongoing 
participation in the voluntary reporting program and applied its 
standard measure selection criteria to identify opportunities to 
improve the Child Core Set.
    MAP supported the continued use of all but one measure in the Child 
Core Set--Percentage of Eligibles That Received Dental Treatment 
Services--because it is not actionable for quality improvement 
purposes. Additionally, MAP requested the phased addition of up to six 
measures to the Child Core Set, two of which are oral health measures 
that would serve as appropriate replacements for the measure suggested 
for removal. Other measures MAP recommended for addition address family 
experience of hospital care, suicide risk assessment for children and 
adolescents with major depression, and birth outcomes.
    MAP members discussed numerous cross-cutting and strategic issues 
related to this reporting program, including limitations in the data 
infrastructure to support measurement, feasibility concerns for 
measures not specified for state-level analysis, and increasing 
alignment of Child Core Set measures with the Medicaid Adult Core Set 
and other quality reporting programs. A major strategic consideration 
for the future direction of the Child Core Set is the large volume of 
pediatric measures in development under the auspices of the AHRQ-CMS 
Pediatric Quality Measures Program (PQMP); these measures will become 
available for MAP's consideration over the course of the next year.

V. Gaps in Endorsed Quality and Efficiency Measures and Evidence and 
Targeted Research Needs

    Under section 1890(b)(5)(iv) of the Act, the entity is required to 
describe gaps in endorsed quality and efficiency measures, including 
measures within priority areas identified by HHS under the agency's 
National Quality Strategy, and where quality and efficiency measures 
are unavailable or inadequate to identify or address such gaps. Under 
section 1890(b)(5)(v) of the Act, the entity is also required to 
describe areas in which evidence is insufficient to support endorsement 
of quality and efficiency measures in priority areas identified by the 
Secretary under the National Quality Strategy and where targeted 
research may address such gaps.
MAP Pre-Rulemaking Input Related to Gap Filling
    NQF continued in 2014 to address the need to fill measurement gaps 
to build on and supplement the analytic work

[[Page 53535]]

that has informed previous Measure Gap Analysis Reports as well as 
other MAP reports. However, much work remains to be done by measure 
developers, NQF, and many other entities to accelerate the closing of 
gaps.
    With each MAP pre-rulemaking cycle, MAP examines progress on both 
alignment and measure gap-filling, and assesses how best to achieve 
these objectives. MAP's 2014 pre-rulemaking review of proposed measures 
submitted by HHS yielded a list of topic areas that needed measures 
that was largely the same as the one developed the previous year. 
Public commenters generally agreed with the gap areas identified on the 
NQF list, which include gaps in:
     Safety: Healthcare-associated infections, medication and 
infusion safety, perioperative/procedural safety, pain management, 
venous thromboembolism, falls and mobility, and obstetric adverse 
events;
     Patient and family engagement: Person-centered 
communication, shared decisionmaking and care planning, advanced 
illness care, and patient-reported measures;
     Healthy living: Well-being, healthy lifestyle behaviors, 
social and environmental determinants of health, social connectedness 
for people with long-term services and supports needs, sense of 
control/autonomy/self-determination, and safety risk assessment;
     Care coordination: Communication, care transitions, system 
and infrastructure support, and avoidable admissions and readmissions;
     Affordability: Ability to obtain follow-up care, total 
cost of care, consideration of patient out of pocket cost, and use of 
radiographic imaging in the pediatric population;
     Prevention and treatment of leading causes of mortality: 
Primary and secondary prevention, cancer, cardiovascular conditions, 
depression, diabetes, and musculoskeletal conditions.
    MAP has observed mixed results in filling measure gaps. An example 
of a success story is the CAHPS In-Center Hemodialysis Survey measure 
(NQF #0258) for the ESRD Quality Incentive Program that MAP supported 
in its 2014 review because it fills a previously identified measure gap 
in consumers' experience of care. HHS now plans to implement this 
measure.
    NQF is working with measure developers and other stakeholders to 
more rapidly expand the pipeline of new measures that may ultimately 
become endorsed. Such efforts include more frequent measure submission 
and endorsement review opportunities, consideration of new approaches 
to endorsement dependent on application, implementation of trial use 
endorsement designation for e-measures, and exploring the development 
of a measure incubator.
    In the meantime, the drive to expeditiously fill measure gaps 
played a role in MAP's decision to support a limited number of 
measures--less than 20--that are currently not NQF-endorsed with 
expectations that they would be later reviewed for endorsement by NQF. 
MAP also noted critical measure gap areas during the creation of 
measure families. If maintained and applied broadly, measure families 
can help achieve increased alignment and keep attention focused on 
high-priority measure gaps. Public commenters expressed strong support 
for the use and continued development of MAP measure families.
Priority Setting for Health Care Performance Measurement: Addressing 
Performance Gaps in Priority Areas
    In an effort to get more specific and detailed guidance to 
developers with respect to key measurement gap areas, HHS requested in 
2013 that NQF recommend priorities for performance measurement 
development across five topics areas specified by HHS, including:
     Adult immunization--identifying critical areas for 
performance measurement to optimize vaccination rates and outcomes 
across adult populations;
     Alzheimer's disease and related dementias--targeting a 
high-impact condition with complex medical and social implications that 
impact patients, their families, and their caregivers;
     Care coordination--focusing on team-based care and 
coordination between providers of primary care and community-based 
services in the context of the ``health neighborhood'';
     Health workforce--emphasizing the role of the workforce in 
prevention and care coordination, linkages between healthcare and 
community-based services, and workforce deployment; and
     Person-centered care and outcomes--considering measures 
that are most important to patients--particularly patient-reported 
outcomes--and how to advance them through health information 
technology.
    In 2014, NQF has completed these analyses through the use of topic-
specific committees that were tasked with reviewing the evidence base 
and existing measures to identify opportunities for using performance 
measurement to improve health and healthcare, as well as to reduce 
disparities, costs, and measurement burden. After these environmental 
scans, the committees then developed measurement frameworks for each 
topic which helped identify measure gap areas. In 2014, NQF submitted 
five final reports to HHS (Adult Immunization, Care Coordination, 
Health Workforce, Person-Centered Care and Outcomes, and Alzheimer's 
Disease and Related Dementias). These five reports are described in 
more detail below.
Adult Immunization
    The Adult Immunization Committee--with the help of an advisory 
group--submitted a report titled, Priority Setting for Healthcare 
Performance Measurement: Addressing Performance Measure Gaps for Adult 
Immunizations,\26\ in August 2014 that builds on concepts identified by 
the Quality and Performance Measures Workgroup of the HHS Interagency 
Adult Immunization Task Force, and seeks to illustrate measure gaps in 
specific age bands and special populations including young adults, 
pregnant women, the elderly, and adults overall.
    A total of 225 unique measures or concepts were identified as 
relevant to adult immunization. An analysis of the identified measures 
showed that there is a plethora of measures that address influenza 
immunization (79 measures, 35 percent of identified measures) and 
pneumococcal immunization (60 measures, 27 percent of identified 
measures). The majority of measures identified in the environmental 
scan are process measures (69 percent) and only 4 of the 46 outcome 
measures are at the provider level; the majority are population and 
surveillance measures.
    The Committee then developed and used a conceptual measurement 
framework to prioritize measurement needs and identify more than 30 
potential measure gaps. The gaps were grouped into several measure 
categories requested by HHS: Adult vaccines for which there are no NQF-
endorsed measures; vaccines for specific age groups consistent with the 
adult immunization schedule issued by Advisory Committee on 
Immunization Practices of the Centers for Disease Control and 
Prevention (ACIP/CDC); vaccines for specific populations such as 
persons with diabetes or other chronic conditions; vaccines for 
healthcare personnel; composite measures including both immunizations 
alone and composite measures that include other clinical preventive 
services; outcome measures; and

[[Page 53536]]

measures for Immunization Information Systems.
    The Committee then discussed the results at an in-person meeting 
and agreed upon the 10 measure gap priorities listed below.

Age-Specific Priorities

 HPV vaccination catch-up for females ages 19-26 years and for 
males-ages 19-21 years
 Tdap/pertussis-containing vaccine for ages 19+ years
 Zoster vaccination for ages 60-64 years
 Zoster vaccination for ages 65+ years (with caveats)

Composite Measure Priorities

 Composite including immunization with other preventative care 
services as recommended by age and gender
 Composite of Tdap and influenza vaccination for all pregnant 
women (including adolescents)
 Composite including influenza, pneumococcal, and hepatitis B 
vaccination measures with diabetes care processes or outcomes for 
individuals with diabetes
 Composite including influenza, pneumococcal, and hepatitis B 
vaccinations measures with renal care measures for individuals with 
kidney failure/end-stage renal disease (ESRD)
 Composite including Hepatitis A and B vaccinations for 
individuals with chronic liver disease
 Composite of all ACIP/CDC recommended vaccinations for 
healthcare personnel

    To provide further guidance, the Committee also identified two 
short-term and long-term priorities from the list of 10 measure gap 
priorities above:
    Short-Term Priorities:

 HPV vaccination catch-up for females ages 19-26 years and for 
males ages 19-21 years
 Composite of Tdap and influenza vaccination for all pregnant 
women (including adolescents)

    Long-Term Priorities:

 Composite measures that include immunization with other 
preventive care services
 Composite measures for healthcare personnel of all ACIP/CDC 
recommended vaccines
Alzheimer's Disease and Related Dementias
    The Alzheimer's Disease and Related Dementias Committee was charged 
with developing a conceptual measurement framework and recommending 
priorities for future performance measurement development in this area. 
NQF submitted a draft conceptual framework and environmental scan in 
February 2014 which was used by the committee to create their final 
report, Priority Setting for Healthcare Performance Measurement: 
Alzheimer's.\27\
    The project's environmental scan yielded 125 dementia-specific 
performance measures. To identify measure gaps, NQF staff mapped these 
measures to the National Quality Strategy priority areas. This analysis 
showed that there is a need for performance measures focused on the 
well-being of caregivers, person- and family-centered measures, and 
outcome measures focused on quality of life and experience of care, and 
measures of affordability.
    Using the information from the environmental scan, the Committee 
developed a conceptual measure framework and recommended priorities for 
future performance measurement development. Five measurement themes 
emerged as the committee deliberated: Importance of connection to 
community-based services, need for accountability at the community 
level, a focus on person- and family-centered approaches, diagnostic 
accuracy, and safety. The committee also recommended the following 
three areas as the highest priority for measure development: Composite 
measure of comprehensive diagnostic evaluation and needs assessment, 
composite measure of caregiver support, and measures to reflect a 
dementia-capable healthcare and community care system.
    Finally, the Committee identified broad recommendations for 
performance measurement related to dementia as well as overarching 
policy recommendations. These recommendations included stratifying 
existing performance measures to assess quality of care for those with 
dementia, modifying the CAHPS surveys to allow proxy response for those 
with dementia so that their experience of care can be recorded, and 
using existing data sources to aid research that could identify those 
who should be assessed for cognitive impairment.
Care Coordination
    The multistakeholder Expert Committee guiding this work focused on 
examining opportunities to measure care coordination, particularly 
between providers of primary care and health-related services provided 
in the community. The conceptual framework adopted by the Committee 
describes a three-way set of relationships between care recipients, 
clinics/clinicians, and community resources. The framework notes that 
the most powerful measures that could be developed would capture the 
interaction of all three elements. The Committee also provided 
additional recommendations to enhance the practice of care coordination 
itself.
    The Care Coordination Committee framework builds on work from the 
Agency for Healthcare Research and Quality's Care Coordination Measures 
Atlas and their Clinical-Community Relationship Measurement concept. 
The project's environmental scan identified a total of 363 measures 
related to care coordination, most of which were general, and uncovered 
very few measures related to ongoing interactions between primary care 
and community-based service providers to support improved health and 
quality of life. In general, currently available measures are either 
too narrowly or too broadly designed to be actionable by providers of 
primary care. Further, no available measures directly apply to 
providers of community services.
    The Committee recommended quick and deliberate action in their 
report, Priority Setting for Healthcare Performance Measurement: 
Addressing Performance Measure Gaps in Care Coordination,\28\ 
particularly in filling performance measure gaps in four high-impact 
areas:
    1. Linkages and synchronization of care and services to promote the 
purposeful collaboration of all members of a care team, achieved 
through continuous monitoring of individuals' care plans, 
multidirectional communication, and problem-solving.
    2. Individuals' progression toward goals for their health and 
quality of life, with measurement centered on whether care recipients 
have a person-centered care plan and the support required to make 
reasonable progress toward their goals.
    3. A comprehensive assessment process that incorporates the 
perspective of a care recipient and anyone who plays a role in 
addressing that person's needs; both medical and psychosocial risk 
factors should inform the determination of how to coordinate delivery 
of care and supports.
    4. Shared accountability within a care team that hinges upon all 
team members understanding their responsibilities for contributing to 
progress toward the care recipient's goals.
    Successful care coordination relies upon the execution of a care 
plan that includes a structured arrangement of standardized data 
elements. However, such standardization is not yet widespread and this 
has been a barrier to systematic measurement of care coordination 
activities.

[[Page 53537]]

Health Workforce
    Achieving the National Quality Strategy's aims of better care, 
affordable care, and healthy people/healthy communities requires an 
adequate supply and distribution of a well-trained workforce. 
Therefore, in consultation with HHS and with input from advisory 
members, NQF developed a draft conceptual framework for measurement 
that captures elements necessary for successful and measureable 
workforce deployment. This framework provided the basis for the report, 
Priority Setting for Healthcare Performance Measurement: Addressing 
Performance Measure Gaps for the Health Workforce.\29\
    A total of 252 measures were identified in the environmental scan 
as potential health workforce measures. Large sets of measures were 
found related to training and development, mostly related to 
professional educational programs and the number of graduates in 
specific health professions. Although many measures of patient and 
family experience of care related to workforce performance were 
identified, few measures capturing workforce experience were found. 
Workforce capacity and productivity measures proved to have a 
substantial presence, especially those related to geographical 
distribution and skill mix.
    Eight domains within the framework were identified as key areas for 
measurement:

1. Training, retraining, and development
2. Infrastructure to support the health workforce and to improve access
3. Retention and recruitment
4. Assessment of community and volunteer workforce
5. Experience (health workforce and person and family experience)
6. Clinical, community, and cross disciplinary relationships
7. Workforce capacity and productivity
8. Workforce diversity

    Within the eight domains above, the Committee identified the five 
highest priority domains for measurement in the near term, and 
recommended concepts for measurement.
    Public comments echoed the Committee's acknowledgement of new and 
future initiatives in this area, which will impact and improve 
workforce measurement, particularly those that capture person- and 
family-centered perspectives, and address vulnerable populations and 
under-resourced geographic areas. Future measure development could 
focus on measures of health workforce deployment and use resulting in 
the greatest impact on health outcomes.
Person-Centered Care and Outcomes
    HHS charged NQF with convening a multistakeholder committee to 
prioritize the person- and family-centered care performance measurement 
gaps that need to be addressed. The Committee provided its 
recommendations in the report, Priority Setting for Healthcare 
Performance Measurement: Addressing Performance Measure Gaps in Person-
Centered Care and Outcomes.\30\
    The Committee highlighted three key principles that should inform 
the identification of measure concepts for person- and family-centered 
care. The concepts are:
     Selected and/or developed in partnership with individuals 
to ensure measures are meaningful to those receiving care;
     focused on the person's entire care experience, rather 
than a single setting, program, or point in time; and
     measured from the person's perspective and experience.
    The Committee identified specific measure concepts for potential 
measure development, and recommended priorities for measuring 
performance on person- and family-centered care. Overarching 
recommendations included integrating individual and family input into 
performance measure development decisions, focusing measurement on 
person-reported experiences, going beyond silos of accountability and 
measurement by challenging the norms of the current healthcare 
environment, and considering how those being measured would act on the 
information.
    In the short term, the Committee had several recommendations that 
could be implemented almost immediately by providers and healthcare 
systems when caring for patients. These recommendations include 
focusing on patients with higher levels of need such as those with 
comorbidities, advanced dementia and other serious illnesses; 
considering the use of Consumer Assessment of Healthcare Providers and 
Systems (CAHPS) performance measures; and convening CAHPS and Patient 
Reported Outcomes Measurement Information System (PROMIs) experts for 
mutual learning in applying new methods of measurement.
Identifying Other Measure Gaps
    NQF identified additional high-priority measure gaps as a natural 
byproduct of NQF's endorsement and maintenance work. Those gaps are 
listed by topic area in Appendix E of this report.
    In addition to identifying gaps through measure endorsement work 
and through the topical gaps reports, the Dual Eligible Beneficiaries 
Workgroup identified the following gaps in their report, 2014 Input on 
Quality Measures for Dual Eligible Beneficiaries:\31\

 Goal-directed, person-centered care planning and 
implementation
 Shared decisionmaking
 Systems to coordinate healthcare with nonmedical community 
resources and service providers
 Beneficiary sense of control/autonomy/self-determination
 Psychosocial needs assessment and care planning
 Community integration/inclusion and participation
 Optimal functioning (e.g., improving when possible, 
maintaining, managing decline)

    Importantly, this list reflects the MAP's vision specifically for 
high-quality care for Medicare-Medicaid enrollees but also applies more 
broadly to the general population as MAP has articulated in previous 
reports. Identification of these gaps supports a philosophy about 
health that broadly accounts for individuals' health outcomes, personal 
wellness, social determinants (e.g., housing, transportation, access to 
community resources), and desire for a more cohesive system of care 
delivery. Many gaps are long-standing, which underscores both the 
importance of nonmedical supports and services in contributing to 
improved healthcare quality and the difficulty of quantifying and 
measuring these factors as indicators of performance.
    Specifically, MAP recommends for future measure development 
continuing a focus on topics that address the social issues that affect 
health outcomes in vulnerable populations, including individuals with a 
history of incarceration and veterans of military service. MAP will 
continue to communicate with measure developers and other stakeholders 
positioned to help fill measurement gaps.
    Although MAP's work to-date on measure gaps--including the pre-
rulemaking efforts and input from specific workgroups--is starting to 
bear fruit, persistent gaps across sectors, such as care coordination 
and patient experience of care, continue to frustrate measurement 
efforts. Current measures fail to capture the complex and dynamic array 
of conditions that are at play in an acutely or chronically ill 
person's life over time. Resources outside of MAP's control need to be 
allocated to research that can explore new methodologies for 
measurement of complex topics such as nonclinical processes and person-
centered outcomes. However, MAP, in

[[Page 53538]]

coordination with NQF's larger initiatives, will continue to try to 
influence ongoing progress in filling measure gaps through its specific 
recommendations and by enhanced collaboration with other stakeholders.

VI. Conclusion and Looking Ahead

    NQF has evolved in the 15 years it has been in existence and since 
it endorsed its first performance measures more than a decade ago. 
While its focus on improving quality, enhancing safety, and reducing 
costs by endorsing performance measures has remained a constant, its 
role has expanded through both public and private support, including 
from foundations and member dues.
    More specifically, NQF has convened multiple private sector 
stakeholders to help inform the development and implementation of the 
first-ever National Quality Strategy and to advise CMS on selection of 
measures for 20 plus federal programs. Other examples of recent work 
beyond endorsement include an NQF-funded Kaizen, or lean, process 
improvement undertaken to streamline MAP and performance measurement 
processes in conjunction with CMS and ONC. In 2014, NQF also worked 
with CMS and America's Health Insurance Plans (AHIP) to identify a 
common, discrete set of aligned measures that both the public and 
private payers agree to request from physicians and other providers.
    With respect to NQF's recent work through MAP to identify measure 
gaps in order to catalyze the field to fill them, several important 
conclusions have been drawn. MAP reported in its 2014 pre-rulemaking 
review of proposed measures that the topic areas that need measures 
were largely the same as from the previous year. Those gaps are in 
safety, patient and family engagement, healthy living, care 
coordination, affordability, and prevention and treatment of leading 
causes of mortality. Measure development in these areas should be a 
priority. NQF's initial efforts to define in detail measures needed in 
these and other high-priority areas may help fill these gaps. NQF is 
also exploring efforts to partner with other organizations to address 
persistent measure gaps, including potential development of a measure 
incubator.
    In 2015, with funding from HHS, NQF is tackling several critical 
issues affecting healthcare quality and safety that will help advance 
the aims and priorities of the National Quality Strategy, as well as 
building on landmark work done in 2014 such as readmissions and issues 
regarding risk adjustment for socioeconomic and sociodemographic 
factors. The work in the year ahead will include NQF simultaneously 
culling and building out a measurement portfolio that drives the 
healthcare system to delivering higher value healthcare at lower cost. 
NQF will also serve as a forum for all stakeholders across the public 
and private sectors to contribute to furthering the future of 
measurement and quality improvement for the nation.

Appendix A: 2014 Activities Performed Under Contract With HHS

----------------------------------------------------------------------------------------------------------------
                                                                  Status (as of 12/31/      Notes/scheduled or
             Description                        Output                   2014)            actual completion date
----------------------------------------------------------------------------------------------------------------
1. Recommendations on the National Quality Strategy and Priorities
----------------------------------------------------------------------------------------------------------------
Multistakeholder input on a National   A common framework that  Phase 1 completed......  Phase 1 completed
 Priority: Improving Population         offers guidance on                                August 2014.
 Health by Working with Communities.    strategies for
                                        improving population
                                        health within
                                        communities.
                                                                Phase 2 in progress....  Phase 2 in progress.
Multistakeholder input into the        Review and input into    Completed..............  Completed January 2014.
 Quality Rating System.                 core measures and
                                        organization of
                                        information for the
                                        Health Insurance
                                        Marketplaces Quality
                                        Rating System.
Multistakeholder Action Pathway Model  Quarterly reports and    Completed..............  Quarterly meetings held
 in support of the Partnership for      meetings detailing                                on:
 Patients (PfP) Initiative.             progress of three                                 January 29,
                                        action teams                                      2014
                                        addressing maternity                              April 24, 2014
                                        care, readmissions,                               July 14, 2014
                                        and patient and family                            October 3,
                                        engagement.                                       2014.
                                                                                         Quarterly reports
                                                                                          released on:
                                                                                          January 31,
                                                                                          2014
                                                                                          April 30, 2014
                                                                                          July 31, 2014
                                                                                          October 15,
                                                                                          2014.
Common Formats for patient safety      A set of comments and    In progress............  Completed-comments
 data.                                  advice for further                                received in 2014
                                        refining additional                               reviewed by Expert
                                        modules for the Common                            Panel and given to
                                        Formats, an AHRQ-based                            AHRQ.
                                        initiative that helps
                                        standardize electronic
                                        reporting of patient
                                        safety event data.
----------------------------------------------------------------------------------------------------------------
2. Quality and Efficiency Measurement Initiatives
----------------------------------------------------------------------------------------------------------------
Behavioral health....................  Set of endorsed          Phase 2 Completed......  Phase 2 endorsed 20
                                        measures for                                      measures in May 2014.
                                        behavioral health.
                                                                Phase 3 in progress....  Phase 3 will be
                                                                                          completed in May 2015.
Readmissions and all-cause admissions  Set of endorsed          In progress............  Will be completed in
 and readmissions measures and          measures for                                      March 2015.
 maintenance review.                    admissions and
                                        readmissions.
Cost and resource use measures.......  Set of endorsed          Phase 2 in progress....  Phase 2 will be
                                        measures for cost and                             completed in March
                                        resource use.                                     2015.
                                                                Phase 3 in progress....  Phase 3 will be
                                                                                          completed in March
                                                                                          2015.

[[Page 53539]]

 
Cardiovascular measures and            Set of endorsed          Phase 1 Completed......  Phase 1 completed
 maintenance review.                    measures for                                      November 2014.
                                        cardiovascular
                                        conditions.
                                                                Phase 2 in progress....  Phase 2 will be
                                                                                          completed in July
                                                                                          2015.
                                                                Phase 3 in progress....  Phase 3 will be
                                                                                          completed in April
                                                                                          2016.
Endocrine measures and maintenance     Set of endorsed          Phase 1 Completed......  Phase 1 was completed
 review.                                measures for endocrine                            in November 2014.
                                        conditions.
                                                                Phase 2 in progress....  Phase 2 will be
                                                                                          completed in February
                                                                                          2015.
                                                                Phase 3 in progress....  Phase 3 will be
                                                                                          completed in September
                                                                                          2015.
Health and well-being measures and     Set of endorsed          Phase 1 Completed......  Phase 1 was completed
 maintenance review.                    measures for health                               in December 2014.
                                        and well-being.
                                                                Phase 2 in progress....  Phase 2 will be
                                                                                          completed in December
                                                                                          2015.
Patient safety measures and            Set of endorsed          Phase 1 in progress....  Phase 1 will be
 maintenance review.                    measures for patient                              completed in January
                                        safety.                                           2015.
                                                                Phase 2 in progress....  Phase 2 will be
                                                                                          completed in February
                                                                                          2016.
Care coordination measures and         Set of endorsed          Completed..............  Was completed in
 maintenance review.                    measures for care                                 November 2014.
                                        coordination.
Musculoskeletal measures and           Set of endorsed          In progress............  Will be completed in
 maintenance review.                    measures for                                      January 2015.
                                        musculoskeletal
                                        conditions.
Person- and family-centered care       Set of endorsed          Phase 1 in progress....  Phase 1 will be
 measures and maintenance review.       measures for person-                              completed in March
                                        and family-centered                               2015.
                                        care.
                                                                Phase 2 in progress....  Phase 2 will be
                                                                                          completed in August
                                                                                          2015.
Surgery measures and maintenance       Set of endorsed          Phase 1 in progress....  Phase 1 will be
 review.                                measures for surgery.                             completed in February
                                                                                          2015.
                                                                Phase 2 in progress....  Phase 2 will be
                                                                                          completed in October
                                                                                          2015.
Eye care, ear, nose, and throat        Set of endorsed          In progress............  Final report will be
 conditions measures and maintenance    measures for eye care,                            completed in January
 review.                                ear, nose, and throat                             2016.
                                        conditions.
Renal measures and maintenance review  Set of endorsed          In progress............  Final report will be
                                        measures for renal                                completed in December
                                        care.                                             2015.
Episode grouper criteria.............  Report examining         Completed..............  Final report completed
                                        necessary submission                              September 2014.
                                        elements for
                                        evaluation, as well as
                                        best practices for
                                        episode grouper
                                        construction.
Prioritization and identification of   Report will provide a    In progress............  Final report will be
 health IT patient safety measures.     comprehensive                                     completed in February
                                        framework for                                     2016.
                                        assessment of HIT
                                        safety measurement
                                        efforts.
Quality measurement for home and       Report will provide a    In progress............  Final report will be
 community-based services.              conceptual framework                              completed in September
                                        and environmental scan                            2016.
                                        to address performance
                                        measure gaps in home
                                        and community-based
                                        services to enhance
                                        the quality of
                                        community living.
Risk Adjustment for socioeconomic      Report providing a set   Completed..............  Final report completed
 status or other sociodemographic       of recommendations on                             August 15, 2014.
 factors.                               the inclusion of
                                        socioeconomic status
                                        and other
                                        sociodemographic
                                        factors in risk
                                        adjustment for outcome
                                        and resource use
                                        performance measures.
Rural health.........................  This project will        In progress............  Final report will be
                                        provide                                           completed in September
                                        recommendations to HHS                            2015.
                                        on performance
                                        measurement issues for
                                        rural and low-volume
                                        providers.
----------------------------------------------------------------------------------------------------------------
3. Stakeholder Recommendations on Quality and Efficiency Measures and National Priorities
----------------------------------------------------------------------------------------------------------------
Recommendations for measures to be     Measure Applications     Completed..............  Completed January 31,
 implemented through the 2014 federal   Partnership Pre-                                  2014.
 rulemaking process for public          Rulemaking Report:
 reporting and payment.                 Input on Measures
                                        Under Consideration by
                                        HHS for 2014
                                        Rulemaking.

[[Page 53540]]

 
Recommendations for measures to be     Measure Applications     In progress............  Measure specific
 implemented through the 2015 federal   Partnership Pre-                                  recommendations will
 rulemaking process for public          Rulemaking Report:                                be completed on
 reporting and payment.                 Input on Measures                                 February 1, 2015.
                                        Under Consideration by                           Hospital, PAC/LTC
                                        HHS for 2015                                      Programmatic Report
                                        Rulemaking.                                       will be completed on
                                                                                          February 15, 2015.
                                                                                         Clinician and Cross
                                                                                          Cutting Report will be
                                                                                          completed on March 15,
                                                                                          2015.
Synthesizing evidence and convening    New families of          Completed..............  Completed July 1, 2014.
 key stakeholders to make               measures covering
 recommendations on families of         affordability,
 measures and risk adjustment.          population health, and
                                        person- and family-
                                        centered care. Also a
                                        final set of
                                        recommendations
                                        focused on risk
                                        adjustment for
                                        resource use
                                        performance measures.
Identification of quality measures     Annual input on the      Completed..............  Completed August 29,
 for dual-eligible Medicare-Medicaid    Initial Core Set of                               2014. Next annual
 enrollees and adults enrolled in       Health Care Quality                               recommendations due by
 Medicaid.                              Measures for Adults                               September 1, 2015.
                                        Enrolled in Medicaid,
                                        and additional
                                        refinements to
                                        previously published
                                        Families of Measures.
Identification of quality measures     Annual input on the      In Progress............  Completed November
 for children in Medicaid.              Initial Core Set of                               14th, 2014. Next
                                        Health Care Quality                               annual recommendations
                                        Measures for Children                             due by September 1,
                                        enrolled in Medicaid.                             2015.
----------------------------------------------------------------------------------------------------------------
4. Gaps in Evidence and Targeted Research Needs
----------------------------------------------------------------------------------------------------------------
Priority Setting for Healthcare        Recommended sets of      Completed..............  Completed August 15,
 Performance Measurement: Addressing    priorities for                                    2014.
 Performance Measure Gaps for the       performance
 Health Workforce.                      improvement for the
                                        health workforce.
Priority Setting for Healthcare        Recommended sets of      Completed..............  Completed August 15,
 Performance Measurement: Addressing    priorities for                                    2014.
 Performance Measure Gaps for Adult     performance
 Immunizations.                         improvement for adult
                                        immunizations.
Priority Setting for Healthcare        Recommended sets of      Completed..............  Completed August 15,
 Performance Measurement: Addressing    priorities for                                    2014.
 Performance Measure Gaps in Care       performance
 Coordination.                          improvement for care
                                        coordination.
Priority Setting for Healthcare        Recommended sets of      Completed..............  Completed August 15,
 Performance Measurement: Addressing    priorities for                                    2014.
 Performance Measure Gaps in Person-    performance
 Centered Care and Outcomes.            improvement for person-
                                        centered care and
                                        outcomes.
Priority Setting for Healthcare        Recommended sets of      Completed..............  Completed October 15,
 Performance Measurement: Addressing    priorities for                                    2014.
 Performance Measure Gaps for           performance
 Alzheimer's Disease.                   improvement for person-
                                        centered care and
                                        outcomes.
----------------------------------------------------------------------------------------------------------------

Appendix B: Measure Evaluation Criteria

    Measures are evaluated for their suitability based on 
standardized criteria in the following order:

1. Importance to Measure and Report: https://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#importance
2. Scientific Acceptability of Measure Properties: https://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#scientific
3. Feasibility: https://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#feasibility
4. Usability and Use: https://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#usability
5. Related and Competing Measures: https://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#comparison

    More information is available on the NQF Web site at: https://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#1_2.

Appendix C: Federal Public Reporting and Performance-Based Payment 
Programs Considered by MAP

End-Stage Renal Disease Quality Incentive Program
Home Health Quality Reporting Program
Hospice Quality Reporting Program
Inpatient Rehabilitation Facility Quality Reporting Program
Long-Term Care Hospital Quality Reporting Program
Ambulatory Surgical Center Quality Reporting Program
Hospital-Acquired Condition Reduction Program
Hospital Inpatient Quality Reporting Program
Hospital Outpatient Quality Reporting Program
Hospital Readmission Reduction Program
Hospital Value-Based Purchasing Program
Inpatient Psychiatric Facility Quality Reporting Program
Prospective Payment System (PPS) Exempt Cancer Hospital Quality 
Reporting Program
Medicare and Medicaid Electronic Health Records (EHR) Incentive 
Programs
Medicare and Medicaid Electronic Health Records (EHR) Incentive 
Programs for Eligible Professionals
Medicare Shared Savings Program
Physician Quality Reporting System
Physician Feedback/Value-Based Payment Modifier Program
Physician Compare

Appendix D: MAP Structure, Members, and Criteria for Service

    MAP operates through a two-tiered structure. Guided by the 
priorities and goals of HHS's National Quality Strategy, the MAP 
Coordinating Committee provides direction and direct input to HHS. 
MAP's workgroups advise the Coordinating Committee on measures 
needed for specific care settings,

[[Page 53541]]

care providers, and patient populations. Time-limited task forces 
consider more focused topics, such as developing ``families of 
measures''--related measures that cross settings and populations--
and provide further information to the MAP Coordinating Committee 
and workgroups. Each multistakeholder group includes individuals 
with content expertise and organizations particularly affected by 
the work.
    MAP's members are selected based on NQF Board-adopted selection 
criteria, through an annual nominations process and an open public 
commenting period. Balance among stakeholder groups is paramount. 
Due to the complexity of MAP's tasks, individual subject matter 
experts are included in the groups. Federal government ex officio 
members are nonvoting because federal officials cannot advise 
themselves. MAP members serve staggered three-year terms.

MAP members

Coordinating Committee

Committee Co-Chairs (Voting)

George J. Isham, MD, MS
Elizabeth A. McGlynn, Ph.D., MPP

Organizational Members (Voting)

AARP
    Joyce Dubow, MUP
Academy of Managed Care Pharmacy
    Marissa Schlaifer, RPh, MS
AdvaMed
    Steven Brotman, MD, JD
AFL-CIO
    Shaun O'Brien
American Board of Medical Specialties
    Lois Margaret Nora, MD, JD, MBA
American College of Physicians
    Amir Qaseem, MD, Ph.D., MHA
American College of Surgeons
    Frank G. Opelka, MD, FACS
American Hospital Association
    Rhonda Anderson, RN, DNSc, FAAN
American Medical Association
    Carl A. Sirio, MD
American Medical Group Association
    Sam Lin, MD, Ph.D., MBA
American Nurses Association
    Marla J. Weston, Ph.D., RN
America's Health Insurance Plans
    Aparna Higgins, MA
Blue Cross and Blue Shield Association
    Trent T. Haywood, MD, JD
Catalyst for Payment Reform
    Shaudi Bazzaz, MPP, MPH
Consumers Union
    Lisa McGiffert
Federation of American Hospitals
    Chip N. Kahn, III
Healthcare Financial Management Association
    Richard Gundling, FHFMA, CMA
Healthcare Information and Management Systems Society
    To be determined
The Joint Commission
    Mark R. Chassin, MD, FACP, MPP, MPH
LeadingAge
    Cheryl Phillips. MD, AGSF
Maine Health Management Coalition
    Elizabeth Mitchell
National Alliance for Caregiving
    Gail Hunt
National Association of Medicaid Directors
    Foster Gesten, MD, FACP
National Business Group on Health
    Steve Wojcik
National Committee for Quality Assurance
    Margaret E. O'Kane, MHS
National Partnership for Women and Families
    Alison Shippy
Pacific Business Group on Health
    William E. Kramer, MBA
Pharmaceutical Research and Manufacturers of America (PhRMA)
    Christopher M. Dezii, RN, MBA, CPHQ

Individual Subject Matter Experts (Voting)

Bobbie Berkowitz, Ph.D., RN, CNAA, FAAN
Marshall Chin, MD, MPH, FACP
Harold A. Pincus, MD
Carol Raphael, MPA

Federal Government Liaisons (Non-Voting)

Agency for Healthcare Research and Quality (AHRQ)
    Richard Kronich, Ph.D./Nancy J. Wilson, MD, MPH
Centers for Disease Control and Prevention (CDC)
    Chesley Richards, MD, MH, FACP
Centers for Medicare & Medicaid Services (CMS)
    Patrick Conway, MD, MSc
Office of the National Coordinator for Health Information Technology 
(ONC)
    Kevin Larsen, MD, FACP

Clinician Workgroup

Committee Chair (Voting)

Mark McClellan, MD, Ph.D.
    The Brookings Institution, Engelberg Center for Health Care 
Reform

Organizational Members (Voting)

The Alliance
    Amy Moyer, MS, PMP
American Academy of Family Physicians
    Amy Mullins, MD, CPE, FAAFP
American Academy of Nurse Practitioners
    Diane Padden, Ph.D., CRNP, FAANP
American Academy of Pediatrics
    Terry Adirim, MD, MPH, FAAP
American College of Cardiology
    * Representative to be determined
American College of Emergency Physicians
    Jeremiah Schuur, MD, MHS
American College of Radiology
    David Seidenwurm, MD
Association of American Medical Colleges
    Janis Orlowski, MD
Center for Patient Partnerships
    Rachel Grob, Ph.D.
Consumers' CHECKBOOK
    Robert Krughoff, JD
Kaiser Permanente
    Amy Compton-Phillips, MD
March of Dimes
    Cynthia Pellegrini
Minnesota Community Measurement
    Beth Averbeck, MD
National Business Coalition on Health
    Bruce Sherman, MD, FCCP, FACOEM
National Center for Interprofessional Practice and Education
    James Pacala, MD, MS
Pacific Business Group on Health
    David Hopkins, MS, Ph.D.
Patient-Centered Primary Care Collaborative
    Marci Nielsen, Ph.D., MPH
Physician Consortium for Performance Improvement
    Mark L. Metersky, MD
Wellpoint
    * Representative to be determined

Individual Subject Matter Experts (Voting)

Luther Clark, MD
    Subject Matter Expert: Disparities
    Merck & Co., Inc
Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
    Subject Matter Expert: Palliative Care
    Hospice and Palliative Nurses Association
Eric Whitacre, MD, FACS; Surgical Care
    Subject Matter Expert: Surgical Care
    Breast Center of Southern Arizona

Federal Government Liaisons (Non-Voting)

Centers for Disease Control and Prevention (CDC)
    Peter Briss, MD, MPH
Centers for Medicare & Medicaid Services (CMS)
    Kate Goodrich, MD
Health Resources and Services Administration (HRSA)
    Girma Alemu, MD, MPH

Dual Eligible Beneficiaries Workgroup Liaison (Non-Voting)

Humana, Inc.
    George Andrews, MD, MBA, CPE, FACP, FACC, FCCP

Dual Eligible Beneficiaries Workgroup

Committee Chairs (Voting)

Alice R. Lind, RN, MPH (Chair)
Jennie Chin Hansen, RN, MS, FAAN (Vice-Chair)

Organizational Members (Voting)

AARP Public Policy Institute
    Susan Reinhard, RN, Ph.D., FAAN
American Federation of State, County and Municipal Employees
    Sally Tyler, MPA
American Geriatrics Society
    Gregg Warshaw, MD
American Medical Directors Association
    Gwendolen Buhr, MD, MHS, Med, CMD
America's Essential Hospitals
    Steven R. Counsell, MD
Center for Medicare Advocacy
    Kata Kertesz, JD
Consortium for Citizens with Disabilities
    E. Clarke Ross, DPA
Humana, Inc.
    George Andrews, MD, MBA, CPE
iCare
    Thomas H. Lutzow, Ph.D., MBA
National Association of Social Workers
    Joan Levy Zlotnik, Ph.D., ACSW
National PACE Association
    Adam Burrows, MD
SNP Alliance
    Richard Bringewatt

Matter Experts (Voting)

Mady Chalk, MSW, Ph.D.
Anne Cohen, MPH
James Dunford, MD
Nancy Hanrahan, Ph.D., RN, FAAN
K. Charlie Lakin, Ph.D.
Ruth Perry, MD
Gail Stuart, Ph.D., RN

Federal Government Liaisons (Non-Voting)

Administration for Community Living (ACL)

[[Page 53542]]

    Jamie Kendall, MPP
Centers for Medicare & Medicaid Services (CMS)
    Venesa J. Day
Office of the Assistant Secretary for Planning and Evaluation
    D.E.B. Potter, MS

Hospital Workgroup

Committee Chairs (Voting)

Frank G. Opelka, MD, FACS (Chair)
Ronald S. Walters, MD, MBA, MHA, MS (Vice-Chair)

Organization Members (Voting)

Alliance of Dedicated Cancer Centers
    Karen Fields, MD
American Federation of Teachers Healthcare
    Kelly Trautner
American Hospital Association
    Nancy Foster
American Organization of Nurse Executives
    Amanda Stefancyk Oberlies, RN, MSN, MBA, CNML, Ph.D.(c)
America's Essential Hospitals
    David Engler, Ph.D.
ASC Quality Collaboration
    Donna Slosburg, BSN, LHRM, CASC
Blue Cross Blue Shield of Massachusetts
    Wei Ying, MD, MS, MBA
Children's Hospital Association
    Andrea Benin, MD
Memphis Business Group on Health
    Cristie Upshaw Travis, MHA
Mothers against Medical Error
    Helen Haskell, MA
National Coalition for Cancer Survivorship
    Shelley Fuld Nasso
National Rural Health Association
    Brock Slabach, MPH, FACHE
Pharmacy Quality Alliance
    Shekhar Mehta, PharmD, MS
Premier, Inc.
    Richard Bankowitz, MD, MBA, FACP
Project Patient Care
    Martin Hatlie, JD
Service Employees International Union
    Jamie Brooks Robertson, JD
St. Louis Area Business Health Coalition
    Louise Y. Probst, MBA, RN

Individual Subject Matter Experts (Voting)

Dana Alexander, RN, MSN, MBA
Jack Fowler, Jr., Ph.D.
Mitchell Levy, MD, FCCM, FCCP
Dolores L. Mitchell
R. Sean Morrison, MD
Michael P. Phelan, MD, FACEP
Ann Marie Sullivan, MD

Federal Government Liaisons (Non-Voting)

Agency for Healthcare Research and Quality (AHRQ)
    Pamela Owens, Ph.D.
Centers for Disease Control and Prevention (CDC)
    Daniel Pollock, MD
Centers for Medicare & Medicaid Services (CMS)
    Pierre Yong, MD, MPH

Post-Acute Care/Long-Term Care Workgroup:

Committee Chair (Voting)

Carol Raphael, MPA

Organizational Members (Voting)

Aetna
    Joseph Agostini, MD
American Medical Rehabilitation Providers Association
    Suzanne Snyder Kauserud, PT
American Occupational Therapy Association
    Pamela Roberts, Ph.D., OTR/L, SCFES, CPHQ, FAOTA
American Physical Therapy Association
    Roger Herr, PT, MPA, COS-C
American Society of Consultant Pharmacists
    Jennifer Thomas, PharmD
Caregiver Action Network
    Lisa Winstel
Johns Hopkins University School of Medicine
    Bruce Leff, MD
Kidney Care Partners
    Allen Nissenson, MD, FACP, FASN, FNKF
Kindred Healthcare
    Sean Muldoon, MD
National Consumer Voice for Quality Long-Term Care
    Robyn Grant, MSW
National Hospice and Palliative Care Organization
    Carol Spence, Ph.D.
National Pressure Ulcer Advisory Panel
    Arthur Stone, MD
National Transitions of Care Coalition
    James Lett, II, MD, CMD
Providence Health & Services
    Dianna Reely
Visiting Nurses Association of America
    Margaret Terry, Ph.D., RN

Individual Subject Matter Experts (Voting)

Louis Diamond, MBChB, FCP(SA), FACP, FHIMSS
Gerri Lamb, Ph.D.
Marc Leib, MD, JD
Debra Saliba, MD, MPH
Thomas von Sternberg, MD

Federal Government Liaisons (Non-Voting)

Centers for Medicare & Medicaid Services (CMS)
    Alan Levitt, MD
Office of the National Coordinator for Health Information Technology 
(ONC)
    Elizabeth Palena Hall, MIS, MBA, RN
Substance Abuse and Mental Health Services Administration (SAMHSA)
    Lisa C. Patton, Ph.D.

Appendix E: Specific Measure Gaps Identified Through 2014 Measure 
Endorsement Work

Cost and Resource Use

 Total cost of care
 Consumer out-of-pocket expenses
 Actual prices paid by patients and health plans
 Trends in cost performance over time at the health plan 
level
 Systematic cost drivers
 Costs rolled up from all levels of analysis which can be 
deconstructed to understand costs at lower levels of analysis

Behavioral Health

 Measures specific to child and adolescent behavioral health 
needs
 Outcome measures for substance abuse/dependence that can be 
used by substance use specialty providers
 Quality measures assessing care for persons with 
intellectual disabilities
 Quality measures that align indicators of clinical need and 
treatment selection and ideally, patient preferences
 Measures that assess aspects of recovery-oriented care for 
individuals with serious mental illness
 Measures related to coordination of care across sectors 
involved in the support of persons with chronic mental health 
problems
 Adapt measure concepts for inpatient care to other 
outpatient care settings
 Measures that assess whether evidence based psychosocial 
interventions are being applied consistent with their evidence base
 Expand the number of conditions for which quality of care 
can be assessed in the context of measurement-based care (e.g. suite 
of endorsed measures now available for depression)
 Measurement strategies for assessing the adequacy of 
screening and prevention interventions for general medical 
conditions
 Screening for alcohol and drugs
 Screening for post-traumatic stress disorder and bipolar 
disorder in patients diagnosed with depression

Cardiovascular

 Patient-reported outcome measures for heart failure 
symptoms and activity assessment
 Composite measures for heart failure
 Measures of cardiometabolic risk factors
 ``Episode of care'' composite measure for AMI that includes 
outcome as well as process measures
 Consideration of socioeconomic determinants of health and 
disparities
 Global measures of cardiovascular care

Care Coordination

 Measures focused on health information technology (IT), 
transitions of care, and structural measures
 Cross-cutting measures that span various types of providers 
and episodes of care. Such measures have the potential to be applied 
more broadly and be more useful for those with multiple chronic 
conditions
 Measures of patient-caregiver engagement
 Measures that evaluate ``system-ness'' rather than measures 
that address care within silos
 Outcome and composite measures, which are prioritized by 
both the Committee and MAP over individual process and structural 
measures, but with the recognition that some of these latter 
measures are valuable

Surgery

 Various specialty areas that are still in their infancy in 
terms of quality measurement, including orthopedic surgery, 
bariatric surgery, neurosurgery, and others
 Measures of adverse outcomes that are structured as ``days 
since last event'' or ``days between events''; this could help 
address some of the concerns about measuring low-volume events
 Measures around functional status or return to function 
after surgery, as well as other patient-centered and patient-
reported outcomes like patient experience

[[Page 53543]]

Health and Well-Being

 Measures that assess social, economic, and environmental 
determinants of health
 Measures that assess physical environment (e.g., built 
environments)
 Measures that assess policy (e.g., smoke-free zones)
 Measures that assess health and well-being for specific 
sub-populations (e.g., people with disabilities, elderly)
 Patient and population outcomes linked to improvement in 
functional status
 Counseling for physical activity and nutrition in younger 
and middle-aged adults (18 to 65 years)
 Composites that assess population experience

Endocrine

 Measures of other endocrine-related conditions, 
particularly thyroid disease, both for adults and for the pediatric 
population
 Incidence of heart attacks and strokes among persons with 
diabetes, measured at the health plan level
 Measures of overuse, particularly for thyroid conditions 
(e.g., ultrasound for thyroid nodules, overdiagnosis/overtreatment 
of thyroid cancer)
 Measures for pre-diabetes/metabolic syndrome
 ``Delta'' measures for intermediate clinical outcomes 
(e.g., LDL levels, HbA1c levels)
 Education measures (e.g., for diabetes) that go beyond 
asking if education was provided and instead assesses whether the 
patient was able to understand and apply the education (needed at 
diagnosis, not just when complications arise)
 Measures that utilize other types of patient information 
(e.g., time-in-range measures for patients with continuous glucose 
monitors)
 More complex measures, including composite measures for 
diabetes screening and for neuropathy care
 Measures of hypoglycemia among the elderly, including 
medication safety measures
 Measures focusing on the use of testosterone
 Measures of Body Mass Index (BMI) or in adult patients with 
diabetes mellitus
 Patient-centered measures of lifestyle management and 
health-related quality of life
 Access to care and medications
 Treatment preferences, psychosocial needs, shared 
decisionmaking, family engagement, cultural diversity, and health 
literacy
 Communication, coordination, and transitions of care
 General prevention and treatment of diabetes, as well as 
measures of the sequelae of diabetes
 Glycemic control for complex patients (e.g., geriatric 
population, multiple chronic conditions) and for the pediatric 
population at the clinician, facility, and system levels of analysis
 Evaluation of bone density, and prevention and treatment of 
osteoporosis in ambulatory settings

Patient Safety

 Safety outcome measures, particularly mediation safety 
measures
 Radiation safety measures

Musculoskeletal

 Management of chronic pain
 Use of MRI for management of chronic knee pain
 Tendinopathy: evaluation, treatment, and management
 Outcomes: spinal fusion, knee and hip replacement
 Overutilization of procedures
 Secondary fracture prevention

National Quality Forum, 1030 15th St. NW., Suite 800, Washington, DC 
20005, https://www.qualityforum.org

ISBN 978-1-933875-86-6
(copyright)2015 National Quality Forum

III. Secretarial Comments on the 2015 Annual Report to Congress and the 
Secretary

    The 2015 Annual Report to Congress and the Secretary by the 
National Quality Forum (NQF) shows the range and complexity of issues 
that face all people and organizations working to improve the 
effectiveness and efficiency of health care quality measurement. 
Approximately 16 percent of 600 quality measures in NQF's portfolio of 
endorsed measures were removed and an almost equal percentage of new 
measures were added in 2014, indicating the dynamic and continuously 
evolving nature of the field of quality measurement. The substantial 
progress in strengthening the set of endorsed measures was facilitated 
by collaborations between NQF, the Centers for Medicare & Medicaid 
Services (CMS), the Office of the National Coordinator for Health 
Information Technology, and many other stakeholders that aimed to 
reduce the complexity of the measure endorsement process. The 
streamlined process that resulted enables more measures to be reviewed, 
considered for endorsement, and endorsed as appropriate.
    Having a greater portfolio of endorsed measures is key to HHS' 
efforts to find better ways to deliver health care, pay providers, and 
keep people healthy and safe. HHS uses performance measures across many 
programs to achieve this. For example, the INR Monitoring for 
Individuals on Warfarin measure (NQF # 0555) is endorsed by the CBE and 
adds to the existing set of measures in the Centers for Medicare and 
Medicaid Services (CMS)'s medication management and clinical 
effectiveness portfolios. This measure is especially valuable, because 
it addresses an important issue that can be used to improve patient 
safety and is useful for many CMS initiatives (e.g., CMS's Physician 
Quality Reporting System and the National Action Plan for Adverse Drug 
Event Prevention). The Cardiovascular Health Screening for people with 
Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic 
Medications measure (NQF # 1927) also is ``cross-cutting,'' applicable 
to measurement of such areas as care coordination and clinical 
effectiveness. Further, this measure can be applied to potentially 
reduce health disparities for individuals with mental illness and 
improve population health by incentivizing providers to better manage 
complex chronic conditions. In addition to HHS' use of NQF-endorsed 
measures in current programs, having a strong slate of endorsed 
measures overall will help HHS in its plans to move the Medicare 
program, and the health care system at large, toward paying providers 
based on the quality, rather than the quantity, of care they give 
patients.
    However, this report also presents some weaknesses in the current 
portfolio of endorsed measures available to evaluate health care. With 
respect to healthcare quality, NQF identified that some gaps remain in 
certain measure categories: (1) patient safety (especially for settings 
other than hospitals), (2) patient and family engagement, (3) healthy 
living, (4) care coordination, (5) affordability, and (6) prevention 
and treatment of leading causes of mortality. The report also 
highlights the need for measures of population health, person- and 
family-centered care, and for measures of the intersection of health 
information technology (HIT) and health care safety. With respect to 
measures of the efficiency of healthcare, NQF's report also calls 
attention to the need for better measures of the price and cost of 
health care, noting that current measures focus on direct costs while 
excluding indirect costs that may be significant for persons and 
families, e.g., transportation to and from providers and lost income 
from missing work. NQF reports that much work remains to close the gaps 
in the set of endorsed measures currently available.
    This report also calls attention to the need to increase our 
knowledge about how best to use measures of health care quality and 
efficiency. For example, as healthcare providers increasingly grapple 
with the need to accommodate patient differences including patient 
preferences, social, cultural, economic, and demographic factors in 
order to help people be healthy and safe, public reporting and value 
based payment programs also need to understand the extent to which (and 
if so, how) sociodemographic factors should be

[[Page 53544]]

incorporated into their quality measurements. Similarly, NQF's 
committee studying the use of episode groupers affirmed their value to 
performance measurements, but also concluded that endorsement of any 
particular episode grouper is not yet possible and set forth an agenda 
for additional work.
    These complexities in the science of measurement are mirrored by 
the complexities faced by consumers when using quality and efficiency 
measures to select health plans and providers. The NQF project 
undertaken to provide input on the measures and the hierarchy for HHS' 
proposed Quality Rating System to help consumers select qualified 
health plans through Health Insurance Marketplaces documented the need 
for such rating systems to pay attention not just to what measures 
should be presented to consumers, but also how the measures should be 
displayed to consumers. It documented the need for such efforts to test 
all aspects of information displays with diverse populations, to 
incorporate provider-level quality information within health plan 
quality information, to provide functionality that allows consumers to 
customize and prioritize information to assist in their unique 
decision-making processes; and for such rating systems to continue to 
evolve as new measures are developed. Accomplishing this will help HHS 
provide better information to consumers for informing their choices 
about qualified health plans in the Marketplaces.
    Increasing the number and comprehensiveness of endorsed measures, 
producing new knowledge to inform how best to deploy such measures, and 
making measures of quality and efficiency readily available and 
understandable to all stakeholders are critical components of HHS' work 
in strengthening the health care delivery system and helping people 
stay healthy and safe. HHS recognizes the success of the National 
Quality Forum in bringing together diverse stakeholders and fostering 
consensus to advise HHS' efforts in these areas. In addition, we 
appreciate the many people who participate in NQF's consensus projects 
by contributing their time and expertise in quality measurement. In 
this report, NQF notes that just one of its projects--the public-
private Measure Applications Partnership (MAP), which provides input on 
the selection of performance measures for more than 20 Medicare public 
reporting and performance-based payment programs--now involves 
approximately 150 healthcare leaders and experts from nearly 90 
private-sector organizations as well as liaisons from seven different 
federal agencies.
    Stakeholders convened by NQF include entire communities as well. 
Participants in the population health initiative undertaken by NQF on 
behalf of HHS include the Colorado Department of Health Care Policy and 
Financing; the Community Service Council of Tulsa, Oklahoma; the 
Designing a Strong and Healthy NY (DASH-NY) coalition of New York, NY; 
the Empire Health Foundation of Spokane, Washington; the Kanawha 
Coalition for Community Health Improvement of Charleston, West 
Virginia; Mercy Medical Center and Abbe Center for Community Mental 
Health--A Community Partnership with Geneva Tower, Cedar Rapids, Iowa; 
the Michigan Health Improvement Alliance of Central Michigan; Oberlin 
Community Services and The Institute for eHealth Equity, in Oberlin, 
Ohio; Trenton Health Team, Inc., in Trenton, New Jersey; and The 
University of Chicago Medicine Population Health Management 
Transformation initiative.
    Such coalitions remind us that it takes all stakeholders working 
together to achieve better health care and health.
    HHS thanks the NQF for this past year's work and for bringing 
together diverse stakeholders to achieve consensus in key performance 
measurement areas. We look forward to continuing to work together to 
advance the science and achieve the benefits of performance 
measurement.

IV. Future Steps

    NQF annually undertakes several activities which constitute a 
recurring agenda. These include, for example, the endorsement and 
maintenance of standardized health care performance measures and making 
recommendations on measures under consideration by HHS for use in its 
many Medicare quality reporting and payment programs. In the coming 
year, in addition to the work on these ongoing annual projects, HHS 
will closely follow the progress of several special projects underway 
by NQF. In particular, NQF's two-year trial period which will test 
specific recommendations for attending to potential socioeconomic and 
sociodemographic factors in quality measurement is of interest. This 
project, added to analyses already underway by HHS in response to the 
Improving Medicare Post-Acute Care Transformation Act of 2014 will 
provide a better understanding of how to address these factors in 
quality measurement, reporting and payment policy.
    A second NQF special project focusing on population health, 
including community action to promote healthy living, will also 
contribute to the knowledge base of how to address social determinants 
of health as we seek to create a health care system that promotes 
prevention and wellness and keeps people healthy. This project also 
responds to one of the CBE duties (specified at Section 
1890(b)(7)(a)(ii) of the Act) which requires the CBE to convene multi-
stakeholder groups to provide input on national priorities for 
improvement in population health as identified in the national 
strategy. Specifically, one of the national strategy's three aims is 
to: ``Improve the health of the U.S. population by supporting proven 
interventions to address behavioral, social, and environmental 
determinants of health in addition to delivering higher-quality care.'' 
And one of the NQS' six priorities calls for ``Working with communities 
to promote wide use of best practices to enable healthy living.'' To 
successfully address this aim and priority, multi-stakeholder input is 
needed on how federal, state and local governments and private sector 
community stakeholders can most effectively engage in:
    1. ``Supporting proven interventions to address behavioral, social, 
and environmental determinants of health;'' and
    2. ``Working with communities to promote wide use of best practices 
to enable healthy living.''
    Other special projects to address gaps in measures for people 
dually eligible for Medicaid and Medicare services, and people who use 
long term care services and supports are also of great interest. HHS 
also will be following the progress of a special project to achieve 
greater consistency in the definitions of some of the data elements 
that comprise measures derived from electronic health records. Having 
consistent definitions of these data elements will enable these 
measures to perform more reliably, and promote more efficient 
assessment, endorsement and maintenance of measures derived from 
electronic data sources.
    HHS will also seek to address gaps in measures identified in NQF's 
report, as HHS pursues new measure development and application in its 
value-based purchasing, public reporting, and other quality measurement 
and improvement initiatives.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements.

[[Page 53545]]

Consequently, it need not be reviewed by the Office of Management and 
Budget under the authority of the Paperwork Reduction Act of 1995 (44 
U.S.C. 35).

    Dated: August 24, 2015.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.

    \1\ Throughout this report, a summary of the relevant statutory 
language appears in italicized text.
    \2\ Department of Health and Human Services (HHS). Report to 
Congress: National Strategy for Quality Improvement in Health Care. 
Washington, DC: HHS; 2011. Available at https://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf. Last accessed February 
2015.
    \3\ National Quality Forum (NQF). Report from the National 
Quality Forum: 2012 NQF Measure Gap Analysis. Washington, DC: NQF, 
2013. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72981. Last accessed February 
2015.
    \4\ NQF. MAP 2014 Recommendations on Measures for More Than 20 
Federal Programs. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=74634. Last accessed February 
2015.
    \5\ NQF. Multistakeholder Input on a National Priority: 
Improving Population Health by Working with Communities--Action 
Guide 1.0. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77293. Last accessed February 
2015.
    \6\ NQF. Input on the Quality Rating System for Qualified Health 
Plans in the Health Insurance Marketplaces. Washington, DC: NQF, 
2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=74552. Last accessed February 
2015.
    \7\ Centers for Medicare & Medicaid Services (CMS) Web site. 
Welcome to the Partnership for Patients. Baltimore, MD: 2015. 
Available at https://partnershipforpatients.cms.gov/. Last accessed 
February 2015.
    \8\ NQF. Maternity Action Team Action Pathway: Promoting Healthy 
Mothers and Babies. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77424. Last accessed February 
2015.
    \9\ NQF. Playbook for the Successful Elimination of Early 
Elective Deliveries. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=idItemID=77396. Last accessed February 
2015.
    \10\ NQF. Readmissions Action Team Action Pathway: Reducing 
Avoidable Admissions and Readmissions. Washington, DC: NQF, 2014. 
Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77291. Last accessed February 
2015.
    \11\ NQF. Patient and Family Engagement Action Pathway: 
Fostering Authentic Partnerships between Patients, Families, and 
Care Teams. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77357. Last accessed February 
2015. Last accessed February 2015.
    \12\ NQF. Risk Adjustment for Socioeconomic Status or Other 
Sociodemographic Factors. Washington, DC: NQF, 2014. Available at 
https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77474. Last accessed February 
2015.
    \13\ NQF. Evaluating Episode Groupers: A Report from the 
National Quality Forum. Washington, DC: NQF, 2014. Available at 
https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77592. Last accessed February 
2015.
    \14\ NQF steering committees are comparable to the expert 
advisory committees typically convened by federal agencies.
    \15\ NQF Web site. Patient-Reported Outcomes. Available at 
https://www.qualityforum.org/Projects/n-r/Patient-Reported_Outcomes/Patient-Reported_Outcomes.aspx. Last accessed February 2015.
    \16\ NQF. Risk Adjustment for Socioeconomic Status or Other 
Sociodemographic Factors. Washington, DC: NQF, 2014. Available at 
https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77474. Last accessed February 
2015.
    \17\ NQF. Evaluating Episode Groupers: A Report from the 
National Quality Forum. Washington, DC: NQF, 2014. Available at 
https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77592. Last accessed February 
2015.
    \18\ NQF. Evaluating Episode Groupers: A Report from the 
National Quality Forum. Washington, DC: NQF, 2014. Available at 
https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77592. Last accessed February 
2015.
    \19\ Weiner JP, Kfuri T, Fowles JB. ``E-iatrogenesis'': The most 
critical unintended consequence of CPOE and other HIT. J Am Med 
Inform Assoc. 2007;14(3):387-388.
    \20\ NQF. MAP 2014 Recommendations on Measures for More Than 20 
Federal Programs. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=74634. Last accessed February 
2015.
    \21\ NQF. Finding Common Ground for Healthcare Priorities: 
Families of Measures for Assessing Affordability, Population Health, 
and Person- and Family-Centered Care. Washington, DC: NQF, 2014. 
Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77001. Last accessed February 
2015.
    \22\ NQF. Finding Common Ground for Healthcare Priorities: 
Families of Measures for Assessing Affordability, Population Health, 
and Person- and Family-Centered Care. Washington, DC: NQF, 2014. 
Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77001. Last accessed February 
2015.
    \23\ NQF. Finding Common Ground for Healthcare Priorities: 
Families of Measures for Assessing Affordability, Population Health, 
and Person- and Family-Centered Care. Washington, DC: NQF, 2014. 
Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77001. Last accessed February 
2015.
    \24\ NQF. Finding Common Ground for Healthcare Priorities: 
Families of Measures for Assessing Affordability, Population Health, 
and Person- and Family-Centered Care. Washington, DC: NQF, 2014. 
Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77001. Last accessed February 
2015.
    \25\ NQF. 2014 Input on Quality Measures for Dual Eligible 
Beneficiaries. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77520. Last accessed February 
2015.
    \26\ NQF. Priority Setting for Healthcare Performance 
Measurement: Addressing Performance Measure Gaps for Adult 
Immunizations. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77416. Last accessed February 
2015.
    \27\ NQF. Priority Setting for Healthcare Performance 
Measurement: Addressing Performance Measure Gaps for Dementia, 
including Alzheimer's Disease. Washington, DC: NQF, 2014. Available 
at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=78039. Last accessed February 
2015.
    \28\ NQF. Priority Setting for Healthcare Performance 
Measurement: Addressing Performance Measure Gaps in Care 
Coordination. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77422. Last accessed February 
2015.
    \29\ NQF. Priority Setting for Healthcare Performance 
Measurement: Addressing Performance Measure Gaps for the Health 
Workforce. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77414. Last accessed February 
2010.
    \30\ NQF. Priority Setting for Healthcare Performance 
Measurement: Addressing Performance Measure Gaps in Person-Centered 
Care and Outcomes. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77423. Last accessed February 
2015.
    \31\ NQF. 2014 Input on Quality Measures for Dual Eligible 
Beneficiaries. Washington, DC: NQF, 2014. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=77520. Last accessed February 
2015.

[FR Doc. 2015-21549 Filed 9-3-15; 8:45 am]
 BILLING CODE 4150-05-P