Secretarial Review and Publication of the National Quality Forum 2017 Annual Report to Congress and the Secretary of the Department of Health and Human Services Submitted by the Consensus-Based Entity Regarding Performance Measurement, 35318-35420 [2018-15763]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
[CMS–3348–N]
Secretarial Review and Publication of
the National Quality Forum 2017
Annual Report to Congress and the
Secretary of the Department of Health
and Human Services Submitted by the
Consensus-Based Entity Regarding
Performance Measurement
Office of the Secretary of
Health and Human Services, HHS.
ACTION: Notice.
AGENCY:
This notice acknowledges the
Secretary of the Department of Health
and Human Services’ (the Secretary)
receipt and review of the National
Quality Forum 2017 Annual Report to
Congress and the Secretary submitted by
the consensus-based entity under
contract with the Secretary in
accordance with the Social Security Act.
The Secretary has reviewed and is
publishing the report in the Federal
Register together with the Secretary’s
comments on the report not later than
6 months after receiving the report in
accordance with the Act.
FOR FURTHER INFORMATION CONTACT:
Sophia Chan, (410) 786–5050.
SUPPLEMENTARY INFORMATION:
SUMMARY:
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I. Background
The United States Department of
Health and Human Services (HHS) has
long recognized that a high functioning
health care system that provides higher
quality care requires accurate, valid, and
reliable measurement of quality and
efficiency. The Medicare Improvements
for Patients and Providers Act of 2008
(MIPPA) (Pub. L. 110–275) added
section 1890 of the Social Security Act
(the Act), which requires the Secretary
of the Department of Health and Human
Services (the Secretary) to contract with
the consensus-based entity (CBE) to
perform multiple duties designed to
help improve performance
measurement. Section 3014 of the
Patient Protection and Affordable Care
Act (the Affordable Care Act) (Pub. L.
111–148) expanded the duties of the
CBE to help in the identification of gaps
in available measures and to improve
the selection of measures used in health
care programs.
HHS awarded a competitive contract
to the National Quality Forum (NQF) in
January 2009 to fulfill the requirements
of section 1890 of the Act. A second,
multi-year contract was awarded to NQF
after an open competition in 2012. A
third, multi-year contract was awarded
again to NQF after an open competition
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in 2017. Section 1890(b) of the Act
requires the following:
Priority Setting Process: Formulation
of a National Strategy and Priorities for
Health Care Performance Measurement.
The CBE must 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: (1) Address the health care
provided to patients with prevalent,
high-cost chronic diseases; (2) have the
greatest potential for improving quality,
efficiency, and patient-centered health
care; and (3) may be implemented
rapidly due to existing evidence,
standards of care, or other reasons.
Additionally, the CBE must take into
account measures that: (1) May assist
consumers and patients in making
informed health care decisions; (2)
address health disparities across groups
and areas; and (3) address the
continuum of care across multiple
providers, practitioners and settings.
Endorsement of Measures: The CBE
must 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: The CBE must
provide for the review and, as
appropriate, the endorsement of the
episode grouper developed by the
Secretary on an expedited basis.
Convening Multi-Stakeholder Groups:
The CBE must convene multistakeholder 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; (2) 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
(3) national priorities for improvement
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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 Act. The multistakeholder groups provide input on
quality and efficiency measures 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 must 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 an annual
report. The report must describe:
• The implementation of quality and
efficiency measurement initiatives and
the coordination of such initiatives with
quality and efficiency initiatives
implemented by other payers;
• Recommendations on an integrated
national strategy and priorities for
health care performance measurement;
• Performance of the CBE’s duties
required under its contract with the
Secretary;
• 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;
• 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
• 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
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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.
The statutory requirements for the
CBE to annually report to Congress and
the Secretary of HHS also specify that
the Secretary 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 6 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 2017 activities to the
Secretary on March 1, 2018. Comments
from the Secretary on the report are
presented in section II of this notice,
and the National Quality Forum 2017
Annual Report to Congress and the
Secretary of the Department of Health
and Human Services is provided, as
submitted to HHS, in the addendum to
this Federal Register notice in section
III.
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II. Secretarial Comments on the
National Quality Forum 2017 Annual
Report to Congress and the Secretary of
the Department of Health and Human
Services
Once again, we thank NQF and the
many stakeholders who participate in
NQF projects for helping to advance the
science and utility of health care quality
measurement. As part of their annual
recurring work to maintain a strong
portfolio of endorsed measures for use
across varied settings of care and health
conditions, NQF reports that in 2017 it
updated its measure portfolio by
reviewing and endorsing or re-endorsing
120 measures and removing 109
measures. Endorsed measures are
developed and implemented with input
from numerous stakeholders. These
measures undergo rigorous testing to
ensure they are evidence-based, reliable,
and valid. Continuous refinement of the
measures portfolio through the
measures maintenance process ensures
that quality measures remain aligned
with current field practices and health
care goals. HHS, with the help of our
partners, is committed to implementing
measures that provide value to payers
and actionable information that can be
used to improve the health of patients.
NQF also undertook and continued a
number of targeted projects dealing with
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difficult quality measurement issues. In
particular, NQF has worked to help
HHS address the unique challenges
faced by rural communities. Nearly one
in five Americans reside in rural
communities.1 HHS recognizes the
unique challenges facing rural America,
and with the support of partners like
NQF, we are leveraging quality
measurement to improve access and
quality for healthcare providers serving
rural patients. NQF recently completed
several projects that focused on rural
health, including Performance
Measurement for Rural Low-Volume
Providers 2 and Creating a Framework to
Support Measure Development for
Telehealth.3 Our reforms in the area of
rural health are part of our overall
strategy to update our programs and
improve access to high quality services.
In 2017, recognizing the need to
strengthen representation of rural
stakeholders in the pre-rulemaking
process, HHS tasked NQF to establish a
Measures Application Partnership
(MAP) Rural Health Workgroup. The
membership of the MAP Rural Health
Workgroup, comprised of 18
organizational members, seven subject
matter experts, and three federal
liaisons, which reflects the diversity of
rural providers and residents and allows
for input from those most affected and
most knowledgeable about rural
measurement challenges and potential
solutions. The MAP Rural Health
Workgroup represents a continuation of
HHS’ effort to address rural health. With
valuable input from our partners and
stakeholders, HHS can continue to
improve health care in rural America.
The MAP Rural Health Workgroup
has focused on identifying a core set of
the best available, ‘‘rural-relevant’’
measures to address the needs of the
rural population. The MAP Rural Health
Workgroup is also working to identify
measurement gaps with respect to rural
communities and provide
recommendations regarding alignment
and coordination of measurement efforts
across both public and private
programs, care settings, specialties, and
sectors (both public and private).
Additionally, the MAP Rural Health
Workgroup provides guidance for the
1 U.S. Census Bureau, 2010 Census, Table
GCTPH1.
2 https://www.qualityforum.org/Publications/
2015/09/Rural_Health_Final_Report.aspx.
3 https://www.qualityforum.org/Publications/2017/
08/Creating_a_Framework_to_Support_Measure_
Development_for_Telehealth.aspx.
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MAP to ensure that measures under
consideration address rural provider
and resident needs and challenges. The
MAP Rural Health Workgroup’s
recommendations are also helping to
address specific barriers to quality
reporting faced by rural clinicians.
Furthermore, the MAP Rural Health
Workgroup has provided a space for
rural clinicians to broadly share their
valuable input. Rural physicians
contribute unique and valuable
perspectives critical to addressing
national challenges, such as the opioid
epidemic. However, rural physicians are
often isolated from national discussions
on relevant measures that could identify
areas of need and gauge prevalence.
Highlighting the valuable input from
rural clinicians opens collaboration
opportunities between rural providers
and providers in other settings as HHS
works to integrate new measures
concerning the prevention and
treatment of opioid and substance use
disorders.
Addressing the needs of rural health
communities is just one of many areas
in which NQF partners with HHS in
enhancing and protecting the health and
well-being of all Americans. HHS
greatly appreciates the ability to
collaborate with diverse stakeholders
and partners to help develop the
strongest possible approaches to quality
measurement as a key component to
health care delivery system reform.
III. Collection of Information
Requirements
This document does not impose
information collection requirements,
that is, reporting, recordkeeping, or
third-party disclosure requirements.
Consequently, there is no need for
review by the Office of Management and
Budget under the authority of the
Paperwork Reduction Act of 1995 (44
U.S.C. 3501 et seq.).
IV. Addendum
In this Addendum, we are publishing
the NQF Report on 2017 Activities to
Congress and the Secretary of the
Department of Health and Human
Services, as submitted to HHS.
Dated: June 21, 2018.
Alex M. Azar II,
Secretary, Department of Health and Human
Services.
BILLING CODE 4120–01–P
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.
NATIONAL
QUALITY FORUM
NQF Report on 2017 Activities to Congress and
the Secretary of the Department of Health and
Human Services
Advance Copy, February 2018
This report was funded by the U.S. Department of Health and Human Services under contract number
HHSM-500-2017-000601 Task Order HHSM-500-T0002.
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Contents
I.
Executive Summary ............................................................................................................................ 4
II.
Recommendations on the National Quality Strategy and Priorities .................................................. 8
Priority Initiative to Improve Rural Healthcare .................................................................................. 9
Quality Roadmap to Reduce Healthcare Disparities and Promote Health Equity ........................... 10
A Framework for Medicaid to Address Social Determinants of Health ........................................... 15
2017 Measurement Guidance for Medicaid and CHIP ..................................................................... 16
Ill.
Quality and Efficiency Measurement Initiatives (Performance Measurement) .............................. 19
Important Changes to NQF Measure Endorsement.. ....................................................................... 19
Cross-Cutting Project to Improve the Measurement Process .......................................................... 23
Social Risk Trial ................................................................................................................................. 24
Measure Endorsement and Maintenance Accomplishments .......................................................... 26
IV.
Stakeholder Recommendations on Quality and Efficiency Measures ............................................. 39
Measure Applications Partnership ................................................................................................... 39
2017 Pre-Rulemaking Input .............................................................................................................. 40
Guidance on Measures Currently in Use .......................................................................................... 40
Other Process lmprovements ........................................................................................................... 40
MAP Clinician Workgroup ................................................................................................................ 41
MAP Hospital Workgroup ................................................................................................................. 43
MAP PAC/LTC Workgroup ................................................................................................................ 46
V.
Gaps on Endorsed Quality and Efficiency Measures Across HHS Programs .................................... 48
VI.
Gaps in Evidence and Targeted Research Needs ............................................................................. 48
Teiehealth ......................................................................................................................................... 49
lnteroperability ................................................................................................................................. 50
Emergency Department Transitions of Care .................................................................................... 52
Improving Diagnostic Quality and Safety ................................................................................ ,. ....... 53
Common Formats for Patient Safety ................................................................................................ 54
Ambulatory Care Patient Safety ....................................................................................................... 55
VII.
Coordination with Measurement Initiatives by Other Payers .......................................................... 55
Quality Measurement Support for the Medicaid Innovation Accelerator Program ........................ 55
Core Quality Measures Collaborative- Private and Public Alignment ............................................ 56
VIII.
Conclusion ........................................................................................................................................ 57
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IX.
References ........................................................................................................................................ 59
Appendix A: 2017 Activities Performed Under Contract with HHS ............................................................ 71
Appendix 8: Medicaid Task Forces and Workgroup Rosters ...................................................................... 74
Appendix C: Scientific Methods Panel Roster ............................................................................................. 77
Appendix D: NQF-Endorsed Measures Adjusted for Social Risk ................................................................. 79
Appendix E: MAP Measure Selection Criteria ............................................................................................. SO
Appendix F: Federal Quality Reporting and Performance-Based Payment Programs Considered by
MAP .............................................................................................................................................................83
Appendix G: MAP Structure, Members, Criteria for Service, and Rosters.................................................. 84
Appendix H: Identified Gaps by NQF Measure Portfolio ............................................................................ 94
Appendix 1: Medicare Measure Gaps Identified by NQF's Measure Applications Partnership .................. 99
Appendix J: Medicaid Measure Gaps Identified by NQF's Medicaid Task Force and the Dual Eligible
Beneficiaries Workgroup ........................................................................................................................., 101
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Executive Summary
Quality measurement is an essential cornerstone of the national movement to achieve high-value
healthcare that ensures meaningful outcomes for patients and reduces spending. The strong, bipartisan
support in the public and private sectors reflects a continued national commitment to invest in quality
measurement as a means to ensure high-quality, cost-effective care and to align healthcare system
priorities to drive greater improvement and reduce unnecessary administrative burden on providers.
Current initiatives to achieve these goals all rely on good, evidence-based quality measures, which help
to identify areas for improvement, gauge success of efforts, reduce provider burden, and support
transparency so that Americans can know that the care they are receiving is safe and effective.
The National Quality Forum (NQF) is an independent organization that brings together public- and
private-sector stakeholders from across the healthcare system to determine the high-value measures
that can best drive improvement in the nation's health and healthcare. NQF facilitates private-sector
recommendations on quality measures proposed for use in federal programs, advances the science of
performance measurement, and identifies and provides direction to address critical clinical, crosscutting areas, called gaps, where quality measures are underdeveloped or nonexistent.
This annual report, NQF Report on 2017 Activities to Congress and the Secretary of the Department of
Health and Human Services, highlights and summarizes the work that NQF performed between January
1 and December 31, 2017 under contract with the U.S. Department of Health and Human Services (HHS)
in the following six areas:
•
•
•
•
•
•
Recommendations on the National Quality Strategy and Priorities;
Quality and Efficiency Measurement Initiatives (Performance Measures);
Stakeholder Recommendations on Quality and Efficiency Measures;
Gaps on Endorsed Quality and Efficiency Measures across HHS Programs;
Gaps in Evidence and Targeted Research Needs; and
Coordination with Measurement Initiatives by Other Payers.
Through two federal statutes and several extensions, Congress has recognized the role of a "consensus
based entity" (CBE}, currently NQF, in helping to forge agreement across the public and private sectors
about what to measure and improve in healthcare. The 2008 Medicare Improvements for Patients and
Providers Act (MIPPA) (PL 110-275) established the responsibilities of the consensus-based entity by
creating section 1890 of the Social Security Act. The 2010 Patient Protection and Affordable Care Act
(ACA) (PL 111-148) 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 consensusbased entity through fiscal year 2013. The Protecting Access to Medicare Act of 2014 (PL 113-93}
extended funding under the MIPPA and ACA statutes to the consensus-based entity through March 31,
2015. Section 207 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) {Pl114-10)
extended funding under section 1890(d)(2) of the Social Security Act for quality measure endorsement,
input, and selection for fiscal years 2015 through 2017. Bipartisan action by numerous Congresses over
several years has reinforced the importance of the role of the CBE.
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In accordance with section 1890 of the Social Security Act, NQF, in its designation as the CBE, is charged
to report annually on its work to Congress and the HHS Secretary.
As amended by the above laws, the Social Security Act (the Act)-specifical/y section 1890(b)(5){A)mandates that the entity report to Congress and the Secretary of the Department of Health and Human
Services (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 an integrated national strategy and priorities for healthcare
performance measurement in all applicable settings;
3) NQF's performance of the duties required under its contract with HHS (Appendix A);
4) gaps in endorsed quality and efficiency measures, including measures that are within priority areas
identified by the Secretary under HHS' national strategy, and where quality and efficiency measures are
unavailable or inadequate to identify or address such gaps;
5) areas in which evidence is Insufficient to support endorsement of measures in priority areas identified
by the National Quality Strategy, and where targeted research may address such gaps; and
6) matters related to convening multistakeholder groups to provide input on: a) the selection of certain
quality and efficiency measures, and b) national priorities for improvement in population health and in
the delivery of heafthcare services for conslderatlofl\under the National Quality Strategy. 1
The deliverables NQF produced under contract with HHS in 2017 are referenced throughout this report,
and a full list is included in Appendix A. Immediately following is a summary of NQF's work in 2017 in
each of the six aforementioned areas. These topics are discussed in further detail in the body of the
report.
Recommendations on the National Quality Strategy and Priorities
NQF brought together organizations in the public and private sectors to help shape national heafthcare
priorities in the National Quality Strategy (NOS) that HHS released in 2011. Supporting these priorities,
in 2017, NQF began or concluded work in several areas of importance, including rural health quality,
healthcare disparities, strategies to address social determinants of health in state Medicaid programs,
and measurement guidance for Medicaid and CHIP.
NQF's multistakeholder Rural Health Committee currently is exploring quality measurement challenges
facing rural providers and will identify a core set of the best available "rural-relevant" measures to
address the healthcare needs of the rural population. In a project that concluded in 2017, NQF's
Disparities Standing Committee created a roadmap for how providers and payers can reduce healthcare
disparities and promote health equity using performance measurement and its associated policy levers.
In another project, NQF developed a framework for state Medicaid programs to better integrate health
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and nonhealth services, using food insecurity and housing instability as examples. NQF also continued to
provide guidance to strengthen core measure sets for Medicaid and CHIP programs.
Quality and Efficiency Measurement Initiatives (Performance Measures)
Healthcare performance measures establish important standards of care and are key to enhancing
healthcare value. NQF's portfolio of endorsed measures contains the most accurate and effective
measures across a variety of clinical and cross-cutting topic areas. Public· and private-sector programs
can use these measures for quality improvement and payment knowing that the measures have met
criteria of scientific acceptability, usability, and feasibility-and can accurately discern the quality of
provider performance.
In 2017, NQF endorsed 120 measures and removed 109 from its portfolio, across 18 endorsement
projects focused on driving the healthcare system to be more responsive to patient and family needs
(e.g., person- and family-centered care, care coordination, pediatrics, and palliative and end-of-life
care), improving care for highly prevalent conditions (e.g., cardiovascular care; renal care; behavioral
health; musculoskeletal health; eye care and ear, nose, and throat conditions; infectious disease;
pediatrics; and cancer), and emphasizing cross-cutting areas to foster better care and coordination (e.g.,
behavioral health, patient safety, cost and resource use, health and well-being, and all-cause admissions
and readmissions).
With input from dozens of public and private stakeholders, NQF continued to refine and improve its
measure endorsement process and implemented significant changes to enhance and streamline
processes. NQF also concluded a two-year trial looking at the impact of including social risk in the riskadjustment models for certain measures, revealing opportunities as well as challenges. In addition, NQF
began a new project to continue to advance understanding of attribution and potential best practices in
quality reporting and value-based payment models.
Stakeholder Recommendations on Quality and Efficiency Measures
The Measure Applications Partnership (MAP) is a public-private partnership convened by NQF that
provides input to HHS on the selection of quality and efficiency measures for pay-for-performance and
quality reporting programs. The private sector also frequently adopts MAP's recommendations. MAP
comprises more than 150 representatives from 90 private-sector stakeholder organizations and seven
federal agencies-ensuring that the federal government receives varied and thoughtful Input on the
selection and continued use of performance measures in quality reporting and payment programs.
MAP's work fosters the use of more uniform measurement across federal programs and the public and
private sectors. Alignment, or use of the same measures, helps better focus providers on key areas in
which to improve quality; reduces wasteful data collection for hospitals, physicians, and nurses; and
helps to curb the proliferation of similar, redundant measures that can confuse patients and payers.
For the 2016-2017 pre-rulemaking process, MAP convened three care setting-specific workgroupsClinician, Hospital, and Post-Acute Care/Long-Term Care (PAC/LTC)-to review proposed measures for
use in Medicare programs. MAP reviewed 74 measures-recommending 65 either for use in a federal
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program or for continued development. MAP workgroups convened again in late 2017 to review 35
measures for the 2017·2018 pre-rulemaking process.
Gaps on Endorsed Quality and Efficiency Measures across HHS Programs
NQF is committed to measurement that drives meaningful improvement in the healthcare system. In
addition to endorsing high-value measures and recommending measures for use in federal programs,
NQF standing committees and MAP, as well as the Medicaid task forces and workgroups, also identify
measure gaps-areas in healthcare where high-value measures are too few or nonexistent-to drive
improvement. These activities alert stakeholders, including measure developers and policymakers,
about pressing measurement needs. The gaps identified in 2017 span conditions, settings, and issues,
from care for costly and prevalent diseases to access to care to patient experience, and more. One
common thread in discussions about gaps was the need for more outcome measures, particularly those
that assess patient-reported outcomes.
Gaps in Evidence and Targeted Research Needs
Several NQF projects completed in 2017, as well as one that is underway, create needed strategic
approaches to measure quality in areas critical to improving health and healthcare for the nation. NQF's
foundational work in these important areas underpins future efforts to improve quality through
measurement and ensure safer, patient-centered, cost-effective care that reflects current science and
evidence.
NQF completed projects to create strategic measurement approaches for assessing the quality of
telehealth, diagnostic safety and accuracy, and transitions of care into and out of emergency
departments. NQF also developed a measurement structure for assessing progress toward
interoperabi!ity, an important area for advancing care that continues to present significant challenges to
healthcare organizations. In other work, NQF continued its efforts to support structured reporting of
patient safety events in hospitals and other care settings. NQF also began a new project to identify
measure concepts that can be used to improve the quality and safety of care in ambulatory care
settings.
Coordination with Measurement Initiatives by Other Payers
NQF completed a project to identify measures to support states' efforts to reform Medicaid payment
and service delivery. The Medicaid Innovation Accelerator project authorized under the ACA section
3021 provided the CMS Center for Medicaid and Children's Health Insurance Program (CHIP) Services
(CMCS) with aligned measure sets across multiple states to support efforts in four high-cost, high-need
areas of care for the Medicaid population: reducing substance use disorders, improving care for
beneficiaries with complex care needs and high costs, promoting community integration through
community-based, long-term care services and supports, and supporting the integration of physical and
mental health.
Adding to NQF's efforts to encourage the use of more meaningful measures and reduce measure burden
on providers, NQF in 2017 continued to contribute technical guidance to the Core Quality Measures
Collaborative workgroups. The initiative, led by America's Health Insurance Plans (AHIP), and which also
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involves the Centers for Medicare & Medicaid Services (CMS), brought together private- and publicsector payers to reach consensus on core performance measures. In 2017, the Collaborative added
pediatrics measures to its sets of clinician-level core measures intended to promote alignment of
measure sets across payers.
II.
Recommendations on the National Quality Strategy and Priorities
Section 1890(b)(l) of the Social Security Act (the Act), mandates that the consensus-based entity (entity)
shall"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
making such recommendations, the entity shall ensure that priority Is given to measures: {i) that address
the health care provided to patients with prevalent, high-cost chronic diseases; (ii) with the greatest
potential for improving the quality, efficiency, and patient-centeredness of health care; and (iii) that may
be implemented rapidly due to existing evidence, standards of care, or other reasons." In addition, the
entity is to "take into account measures that: {i) may assist consumers and patients in making informed
health care decisions; (ii) address health disparities across groups and areas; and {iii) address the
continuum of care a patient receives, including services furnished by multiple health care providers or
practitioners and across multiple settings."2
Additionally, section 1890(b)(S)(A)(vi) of the Social Security Act requires that this report describe matters
related to multistakeholder input on national priorities for improvement in population health and in
delivery of health care services for consideration under the National Quality Strategy.
In 2010, at the request of HHS, the NQF·convened National Priorities Partnership (NPP) provided input
that helped shape the national healthcare priorities in the initial version of the National Quality Strategy
(NQS) that HHS released in March 2011. 3 The Centers for Medicare & Medicaid Services (CMS) continues
to align its work with the priorities of making care safer, strengthening person and family engagement,
promoting effective communication, promoting effective prevention and treatment of chronic disease,
working with communities to promote best practices of healthy living, and making care affordable in
partnership with public and private healthcare stakeholders across the country.
Annually, NQF has continued to endorse measures reflective of these national priorities and convene
diverse stakeholder groups to reach consensus on key strategies for performance measurement and
quality improvement. In 2017, NQF completed or began work in key areas of importance that address
healthcare priorities. This work includes projects to improve measurement of care quality in rural
settings, reduce healthcare disparities, address social determinants of health, and recommend measures
to evaluate care for the population enrolled in Medicaid and CHIP. These initiatives are described below.
Additional projects to develop measurement structures to assess the quality of telehealth, progress
toward interoperability, transitions of care from emergency departments, and the quality and safety of
diagnoses are described in another section of this report, "Gaps in Evidence and Targeted Research
Needs."
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Priority Initiative to Improve Rural Healthcare
More than 59 million Americans-approximately 19 percent of the U.S. population-live in rural areas. 4
Statistics indicate that rural residents may be more disadvantaged overall than those in urban or
suburban areas, particularly with respect to sociodemographic factors, health status and behaviors, and
access to the healthcare delivery system. For example, rural Americans are more likely to be older; have
chronic health conditions; engage in poor health behaviors such as smoking; and have higher rates of
social disadvantages, such as low income, high unemployment, and lower educational attainment. 5•6
Rural Americans are also more likely to experience difficulties accessing primary care, dental, and
mental healthcare, given the shortage of providers in rural areas.7 The continuing trend of rural hospital
closures has also affected rural Americans' ability to access care in their communities. 8
Rural hospitals and clinicians participate in a variety of private-sector, state, and a limited number of
federal quality measurement and improvement efforts. In a 2015 HHS-funded project, NQF convened a
multistakeholder Rural Health Committee to explore in depth the quality measurement challenges
facing rural providers.
Multiple and disparate demands (e.g., direct patient care, business and operational responsibilities)
compete for the time and attention of providers who serve in small rural hospitals, and providers in
rural clinical practices often have limited time, staff, and finances available for quality improvement ·
activities. In addition, some rural areas may lack information technology (IT) capabilities altogether
and/or IT professionals who can leverage those capabilities for quality measurement and improvement
efforts. The heterogeneity of residents in many rural areas, such as a disproportionate number of
vulnerable residents, has particular implications for healthcare performance measurement, including
limited applicability of measures and potentially, the need for modifications in the risk-adjustment
approach for certain measures. 9 Moreover, depending on the particular performance measure, rural
providers may not have enough patients to achieve reliable and valid measurement results. While urban
areas may experience many of these same difficulties, in rural areas they likely pose greater challenges
for, and have greater impact on, quality measurement and improvement activities.
Some measurement challenges are unique to rural providers. For example, many do not participate in
current CMS quality programs because they don't exist, or participate-in the case of Critical Access
Hospitals {CAHs)-only on a voluntary basis, and thus may have limited experience in collecting data and
reporting on healthcare performance measures. Also, claims-based performance measures may not
provide valid results for those rural providers who do not submit comprehensive data because they do
not rely on claims reimbursements for payment.
The NQF Rural Health Committee made a series of recommendations to CMS, particularly in the context
of pay-for-performance programs and improving quality in rural areas. The Committee's overarching
recommendation 10 was to integrate rural healthcare providers into federal quality programs. The
Committee noted that rural providers' nonparticipation in federal quality programs may affect the
ability of these providers to identify and address opportunities for improvement, as well as demonstrate
how they perform compared to their nonrural counterparts.
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The Committee's remaining recommendations were intended to help ease the transition of rural
providers to mandatory participation in CMS quality programs. These recommendations include: to
develop rural-relevant measures (e.g., to address topics such as patient hand-offs and transitions,
address the low case-volume challenge, and include appropriate risk adjustment); align measurement
efforts (including measures themselves, data collection efforts, and informational resources); consider
rural-specific challenges during the measure-selection process, create a rural health workgroup to advise
the Measure Applications Partnership (MAP); and address the design and implementation of pay-for·
performance programs.
In 2017, recognizing the lack of representation from rural stakeholders in the pre-rulemaking process,
CMS tasked NQF to implement the 2015 Rural Health Workgroup's recommendation to establish a MAP
Rural Health Workgroup (see Appendix G). This Workgroup, comprised of 18 organizational members,
seven subject matter experts, and three federal liaisons, was seated in November 2017. Because
Workgroup members reflect the diversity of rural providers and residents, it includes the perspectives of
those most affected and those most knowledgeable about rural measurement challenges and potential
solutions. Input from such rural experts will allow the setting-specific MAP Workgroups and
Coordinating Committee to consider measurement challenges that rural providers face, including the
limitations of current or proposed measures.
A major task of the MAP Rural Health Workgroup will be to identify a core set of the best available,
"rural-relevant" measures to address the needs of the rural population. During its first year, the
Workgroup will focus on measures that are potentially applicable to CMS' hospital inpatient and
outpatient quality reporting programs and its clinician-focused quality reporting programs. The
Workgroup also will identify rural-relevant gaps in measurement and provide recommendations
regarding alignment and coordination of measurement efforts across both public and private programs,
care settings, specialties, and sectors (both public and private). Additionally, the Workgroup will provide
guidance to address a measurement topic relevant to vulnerable individuals in rural areas and will
provide input on Measures Under Consideration (MUC) specific to the needs and challenges of rural
providers and residents. NQF will issue a final report on this work in September 2018. In future years, if
it is funded to continue its work, the Workgroup will shift attention to measures applicable in post-acute
and long-term care settings.
Quality Roadmap to Reduce Healthcare Disparities and Promote Health Equity
Widespread recognition of health and healthcare disparities has prompted HHS as well as many other
organizations in the public and private sectors to prioritize health equity as a key component of
healthcare quality improvement. Disparities are differences caused by inequities that are linked to
social, economic, and/or environmental disadvantages, and these differences persist despite overall
improvements in public health and medicine. Achieving health equity requires eliminating disparities in
healthcare delivery and outcomes by addressing social risk factors that adversely affect excluded or
marginalized groups.
Performance measurement is an essential tool for monitoring health disparities and assessing the level
to which research-based interventions are employed to reduce disparities. Measures can help to
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pinpoint where people with social risk factors do not receive the care they need or receive care that is
lower quality. However, there was no comprehensive approach for HHS and other stakeholders to use
measurement to eliminate disparities and promote health equity.
In 2016, HHS funded NQF to convene the Disparities Standing Committee, a multistakeholder group of
experts (e.g., payers, providers, researchers, and patients) to develop recommendations for how
performance measurement, and its associated policy levers, can be used to reduce disparities in health
and healthcare. NQF documented the project through three interim reports published in 2017, each of
which examines disparities based on social risk factors identified in the 2016 National Academy of
Medicine {NAM) report, Accounting [or Social Risk Factors in Medicare Payment: Identifying Social Risk
Factors, 11 e.g., socioeconomic position, race, ethnicity, residential and community context, and sexual
orientation.
The first interim report, Disparities in Healthcare and Health Outcomes in Selected Conditions, 12
documented disparities in health and healthcare among leading causes of morbidity and mortality for
certain conditions from a review of published literature. These conditions include cardiovascular
diseases, cancer, diabetes and chronic kidney disease, infant mortality/low birthweight, and mental
illness. The report documents significant disparities across all of the selected conditions and highlights
the urgent need for a systematic approach to eliminate disparities through measurement. The report
includes examples of interventions that were successful in reducing disparities, such as improving
outcomes in diabetes and cardiovascular disease. It also cites the 2016 National Healthcare Quality and
Disparities Report, 13 which documents smaller disparities for 20 percent of measures (e.g., care
coordination, patient safety, and affordability) between African Americans and Non-Hispanic Whites.
The second interim report, Effective Interventions in Reducing Disparities in Healthcare and Health
Outcomes in Selected Conditions, 14 identified interventions {e.g., patient education, lifestyle
modification, and culturally tailored programs) that could be used to address disparities documented in
the first interim report. The Disparities Standing Committee and NQF staff reviewed the research on
interventions that have effectively reduced disparities. They found that interventions to reduce
disparities currently are focused largely on reducing disparities based on race and ethnicity. In addition,
interventions are usually implemented to address disparities in one condition or to address disparities
for one social risk factor. The findings indicate potential for multitarget interventions that could address
disparities across conditions and for multiple social factors.
The third interim report, An Environmental Scan of Health Equity Measures and a Conceptual
Framework for Measure Development, 15 documented 886 performance measures that can be used
either to monitor disparities within the selected conditions explored in the first interim report or to
assess the use of evidence-based interventions identified in the second interim report. Most measures
evaluated processes or outcomes of healthcare, and few gauged the use of evidence-based
interventions. The environmental scan pointed to several gaps in measurement and areas for future
research.
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The Disparities Standing Committee used the outcomes of each interim report to inform its. final
recommendations. Published September 2017, the final report, A Roadmap for Promoting Health Equity
and Eliminating Disparities, 16 outlines how the U.S. healthcare system {e.g., providers and payers) can
build on existing standards of care, measurement practices, and payment models to address disparities.
It also identifies areas where collaboration between health and nonhealth sectors and community
linkages can be used to expand the healthcare system's role to better address the upstream causes of
disparities.
The Road map provides guidance for addressing a wide spectrum of disparities based on age, gender,
income, race, ethnicity, nativity, language, sexual orientation, gender identity, disability, geographic
location, and other social risk factors. It emphasizes the importance of cultural competence, community
engagement, and cross-sector partnerships to reduce disparities. In particular, the Roadmap addresses
measurement beyond clinical settings, structures, and processes of care. For example, it Includes the
assessment of collaboration between healthcare and other sectors
schools, social services,
transportation, housing, etc.) to reduce the Impact of social risk factors and achieve health equity.
The Road map suggests actions that healthcare stakeholders can employ to reduce disparities, including:
Prioritize measures that can help to identify and monitor disparities (disparities-sensitive measures).
Measure implementers should prioritize the use of measures that are sensitive to disparities in health
and healthcare. Disparities-sensitive measures detect differences in quality across institutions or in
relation to certain benchmarks, but also differences in quality among population or social groups. The
Roadmap specifies criteria to assist with the prioritization of disparities-sensitive measures.
Implement evidence-based interventions to reduce disparities. Stakeholders should implement
evidence-based interventions to reduce disparities at every level of the healthcare system (i.e.,
government, community, organization, and individual levels).
Invest in the development and use of measures to assess interventions that reduce disparities (health
equity measures). The Committee identified five domains of measurement that should be used together
to reduce disparities and advance health equity. These domains assess the extent to which the
healthcare system:
•
•
•
Collaborates and partners with other organizations or agencies that influence the health of
individuals (e.g., neighborhoods, transportation, housing, education, etc.) to address social
needs.
Adopts and implements a culture of equity. A culture of equity recognizes and prioritizes the
elimination of disparities through genuine respect; fairness; cultural competency; the
creation of environments where all individuals, particularly those from diverse and/or
stigmatized backgrounds, feel safe In addressing difficult topics, e.g., racism; and advocating
for public and private policies that advance equity.
Creates structures that support a culture of equity. These structures include policies and
procedures that institutionalize values that promote health equity, commit adequate
resources for the reduction of disparities, and enact systematic collection of data to monitor
and provide transparency and accountability for the outcomes of individuals with social risk
factors.
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•
•
Ensures equitable access to healthcare. Equitable access means that individuals with social
risk factors are able to easily get care. It also means care is affordable, convenient, and able
to meet the needs of individuals with social risk factors.
Ensures high-quality care that continuously reduces disparities. Performance measures
should be routinely stratified by social risk to identify disparities in care. In addition,
performance measures should be used to create accountability for reducing, and ultimately,
eliminating disparities through effective interventions.
Provide incentives to reduce disparities. Providers and other stakeholders should be incentivized to
reduce disparities through recognition, payment, or additional resources. For example, public and
private payers can adjust payments to providers based on social risk factors or offer additional payments
for primary care or disease management programs (e.g., in-home monitoring of blood pressure).
The Committee suggested ways for sectors of the healthcare system to pursue specific actions, including
that:
•
•
•
•
Hospitals and health plans identify and prioritize reducing disparities and distinguish which they
can address in the short· and long-term;
Clinicians implement evidence-based interventions by connecting patients to community-based
services or culturally tailored programs shown to mitigate the drivers of disparities;
Measure developers work with patients to translate concepts of equity into performance
measures that can directly assess health equity; and
Policymakers and payers incentivize the reduction of disparities and the promotion of health
equity by building health equity measures into new and existing healthcare payment models.
The Committee developed a set of 10 recommendations to support reducing disparities and promoting
health equity, Among its recommendations, the Committee supports providing primary care practices
incentives to support preventive activities for patients with social risk factors. Equitable access starts
with unconstrained access to primary care. Robust systems of primary care are associated with
improved population health and reduced disparities, Primary care plays a unique role in promoting
equity through its comprehensive and biopsychosocial focus, longitudinal personal relationships, and its
capacity to align intensity of care management with patient needs. The Committee's complete list of
recommendations follows:
Recommendation l: Collect social risk factor data.
Data are the bedrock of all measurement activities; however, data on social risk factors are currently
limited. As such, stakeholders must invest in the necessary infrastructure to support data collection.
There is a general need for data collection related to social risks like housing instability, food insecurity,
gender identity, sexual orientation, language, continuity of insurance coverage, etc.
Recommendation 2: Use and prioritize stratified health equity outcome measures.
Stakeholders should first conduct a needs assessment to identify the extent to which they are meeting
the goals outlined in the Road map, The domains of measurement should be considered as a whole
rather than aiming to make progress in only one area. Stakeholders must actively identify and
decommission measures that have reached ceiling levels of performance and where there are
insignificant gaps in performance.
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Recommendation 3: Prioritize measures in the domains of Equitable Access and Equitable HighQuality Care for accountability purposes.
Some measures within the domains of measurement are more suitable for accountability and others, for
quality improvement. The majority of measures that fall within the domains of Culture for Equity,
Structure for Equity, and Collaboration and Partnerships should be used primarily for quality
improvement initiatives and are less appropriate for accountability. Measures that are aligned with the
domains of Equitable Access to Care and Equitable High-Quality Care may be more suitable for
accountability.
Recommendation 4: Invest in preventive and primary care for patients with social risk factors.
Equitable access starts with unconstrained access to primary care. People with low health literacy,
limited eHealth literacy, limited access to social networks for reliable information, or who are challenged
with navigating a fragmented healthcare system often rely on continuity with a trusted primary care
provider. Primary care's capacity to care for people (rather than diseases) across medical, behavioral,
and psychosocial dimensions while providing resources and services to align with these needs is vital to
improving health equity. Ultimately, incentives are needed to prioritize support for traditionally
underfunded preventive activities.
Recommendation 5: Redesign payment models to support health equity.
Payment models designed to promote health equity have the potential to have a large impact on
reducing disparities. For example, health plans can provide upfront payments to fund infrastructure for
achieving equity and addressing the social determinants of health. Health plans also can implement payfor-performance payment models that reward providers for reducing disparities in quality and access to
care. The Committee noted that purchasers could use mixed model approaches, combining payment
models based on their specific goals (e.g., upfront payments and pay-for-performance to reduce
disparities). Payment models can also be phased, using pay-for-reporting, then pay-for-performance
incentives.
Recommendation 6: Link health equity measures to accreditation programs.
Integrating health equity measures into accreditation programs can increase accountability for reducing
disparities and promoting health equity. These measures can be linked to quality improvement-related
equity building activities. Organizations like the National Committee for Quality Assurance (NCQA) and
URAC have already aligned with this strategy.
Recommendation 7: Support outpatient and inpatient services with additional payment for patients
with social risk factors.
Social risk factors are like clinical risk factors in the sense that they require more time and effort on the
part of providers in specific encounters to achieve the same results. If an office visit is more complex
(and billed and paid at a higher level) because of clinical complexity in a patient, the same concept could
extend to the incorporation of social risk factors and "social complexity" as a payment concept.
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Recommendation 8: Ensure organizations disproportionately serving individuals with social nsk con
compete in value-based purchasing programs.
Payers should consider additional payments to assist organizations in developing the infrastructure to
provide high-quality care for people with social risk factors. There is a need to adjust for social risk
factors as well as stratify performance scores by social risk to ensure transparency and drive
improvement. In addition, relevant stakeholders should prospectively monitor the financial impact of
value-based purchasing programs
o~ organizations caring for individuals with social risk factors.
Recommendation 9: Fund care delivery and payment reform demonstration projects to reduce
disparities.
The evidence base for many care delivery and payment reform interventions to reduce healthcare
disparities is still limited. There is a need to better understand what work is being done to reduce
disparities, what interventions are effective, and how these interventions can be replicated in practice
(e.g., implementation science). Future research and demonstration projects should be conducted in
partnership with researchers to ensure they are rigorous and scientifically sound.
Recommendation 10: Assess economic impact of disparities from multiple perspectives.
There is limited understanding of the economic impact of disparities. Quantifying the costs in terms such
as lost productivity, quality-adjusted life years, readmission rates, emergency department use, etc.,
could help organizations understand the imperative to invest in health equity.
A Framework for Medicaid to Address Social Determinants of Health
State Medicaid programs are making significant advances in addressing social determinants of health
(SDOH) to improve health outcomes. 11•18•19 Evidence is growing that SDOH-such as where people live,
how much money they earn, and their level of education-have significant impact on health and wellbeing.20 Several states have implemented waivers and new financing mechanisms to support the
collection of SDOH data and coordination of care based on SDOH. 21 However, the evidence-base for
screening and addressing social needs is still developing. Numerous organizations have called for a
framework to help state Medicaid programs make strategic investments in the collection and use of
SDOH data.
Funded by CMS, NQF convened an Expert Panel to develop a framework for state Medicaid programs to
better integrate health and non health services, using food insecurity and housing instability as
illustrative examples. The Expert Panel included a variety of stakeholder groups such as clinicians,
researchers, health plans, health systems, and consumer advocates. Food insecurity and housing
instability were selected as key areas where state Medicaid programs can support data collection efforts
in the short term.
To support this work, NQF conducted a literature review on the impact of food insecurity and housing
instability on health outcomes, an environmental scan of measures (e.g., screening tools, performance
measures, scales, assessments, etc.}, and key informant interviews. Key informants represented
organizations working to reduce the incidence of food insecurity and housing instability. The interviews
offered insights into barriers and opportunities. For example, many informants cited a lack of resources
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in communities such as food deserts, areas without food banks, and long waiting lists for housing
supports.
The Expert Panel identified a framework that builds on the hub-and-spoke model by Taylor et al., and on
work from the Social Interventions Research & Evaluation Network at the University of California San
Frandsco.n 23 The framework positions Medicaid programs at the "hub" as a primary health care entity
that connects healthcare to non health services that can address social needs (the "spokes") to the
healthcare system. The "spokes" include services like housing supports, food and nutritional supports,
home and community-based services, and employment services. The framework illustrates the role of
Medicaid programs in supporting SDOH Informed Healthcare, using information on social needs in
clinical decision making for Medicaid beneficiaries, and SDOH Targeted Healthcare-connecting
individuals to nonhealth services that can address SOOH (e.g., Temporary Assistance of
Families,
Head Start, and homeless ness assistance programs}.
In its final report, completed December 2017, the Expert Panel shared a set of six recommendations to
support the implementation of the framework:
1. Acknowledge Medicaid has a role in addressing social determinants of health
Create a comprehensive, accessible, routinely updated list of community resources
3. Harmonize tools that assess social determinants of health
4. Create standards for inputting and extracting social needs data from electronic health
records
5. increase information sharing between government agencies
6. Expand the use of waivers and demonstration projects to learn what works best for
screening and addressing SDOH
2.
2017 Measurement Guidance for Medicaid and CHIP
Medicaid is the largest health insurance program in the United States, serving 74 million individuals.
Nearly 36 million, or almost half of the people enrolled in Medicaid and CHIP are children. 24 As the
primary health insurance program for the nation's low-income population, 25 Medicaid
covers many
individuals with a high need for medical and healthcare services, including the growing population of
more than 11 million individuals who are dually eligible for both Medicare and Medicaid. 2• Medicaid
beneficiaries with complex care needs account for roughly 54 percent of total Medicaid expenditures,
despite comprising just 5 percent of all Medicaid beneficiaries. 27 Moreover, Medicaid covers nearly so
percent of all births as well as 40 percent of children's healthcare. 28 Understanding the needs of adults
and children who rely on Medicaid for their healthcare is imperative for improving their health and the
quality of their care.
In 2017, NQF continued its efforts to improve healthcare for the population enrolled in Medicaid and
CHIP by recommending standardized measures to evaluate quality of care across states in key areas.
NQF issued its recommendations on Medicaid's core measures in a series of three reports.
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Strengthening the Core Set of Healthcare Qualfty Measures for Adults Enrolled In Medicaid, 2017111
Section 1139B of the Social Security Act (amended by the ACA) called for the creation of a Core Set of
Health Care Quality Measures for Adults Enrolled in Medicaid (the Adult Core Set) to assess the quality
of care for adults enrolled in Medicaid. HHS established the Adult Core Set to standardize the
measurement of healthcare quality across state Medicaid programs, assist states in collecting and
reporting on the measures, and facilitate use of the measures for quality improvement. 30 In January
2012, HHS published the initial Adult Core Set of measures·in partnership with a subcommittee to the
AHRQ' s National Advisory CounciL 31 The 2017 Adult Core Set contained 30 healthcare qua llty measures.
NQF's Medicaid Adult Task Force recommended improvements to the Adult Core Set annually. The Task
Force also has identified high-priority gaps where more or better quality measures are needed. In its
fifth set of recommendations on the Adult Core Set, published in August 2017, the Task Force
recommended the addition of four measures to address care of patients with asthma, patients'
feedback about the quality of long-term services received in a community setting, opioid use, and
contraceptive use. The Task Force supported the removal of two measures from the Adult Core Set,
citing states' reporting challenges regarding data collection for one measure and encouraging the
addition of a more meaningful replacement for the other that focused on counting office visits, rather
than the content of the visits, to address patient outcomes.
Thirty-nine states reported on at least one of the Adult Core Set measures for federal fiscal year (FFY)
2015. 32 State reporting increased for 20 of the 25 measures included in both the 2014 and 2015 Adult
Core Sets. 33 The gradual addition of measures to the Core Set has a flowed states to build their measure·
reporting infrastructure, as evidenced by the increase in the number of states voluntarily reporting on
measures. The Task Force suggested optimizing data connections between data systems and among
organizations, as well as improving integration across local, state, and federal health entities as some of
the ways states could improve quality and Adult Core Set reporting.
NQF has begun its next annual review of the Adult Core Set with the appointment of a new,
multistakeholder Medicaid Adult Workgroup. The results are due to CMS by the end of August 2018.
Strengthening the Core Set of Heafthcare Quality Measures for Children Enrolled In Medicaid and
CHIP, 201734
The Children's Health and Insurance Program Reauthorization Act of 2009 (CHIPRA) required HHS to
develop standards to measure the quality of children's healthcare. This legislative mandate led to the
identification of the Core Set of Health Care Quality Measures for Children Enrolled in Medicaid and
CHIP (the Child Core Set). CMS released the initial Child Core Set in 2010. Measures in the Child Core Set
are relevant to children ages 0-20 as well as pregnant women because these measures address both
prenatal and postpartum quality-of-care issues. CHIPRA also required CMS to recommend updates to
the initial Child Core Set annually beginning in January 2013. The 2017 Child Core Set contained 27
healthcare quality measures.
NQF's Medicaid Child Task Force has recommended improvements to the Child Core Set annually. The
Task Force also has identified high-priority gaps where more or better quality measures are needed. In
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its fourth set of annual recommendations on the Child Core Set, published in August 2017, the Task
Force recommended the addition of five measures to address access to care, behavioral health, and care
of patients with asthma. The Task Force supported the removal of five measures, citing the need for
better measures that focus on care quality, not frequency of services.
Every state reported on at least some of the Child Core Set measures for FFY 2015. 35 State reporting
increased for 16 of the 23 measures included in both the 2014 and 2015 Child Core Sets. 36 As with the
Adult Core Set, the gradual addition of measures to the Child Core Set has allowed states to build their
measure-reporting infrastructure, as evidenced by the increase in the number of states voluntarily
reporting on measures. The Task Force suggested optimizing data connections between data systems
and among organizations, as well as improving integration across local, state, and federal health entities
as some of the ways states could improve quality and Child Core Set reporting.
NQF has begun its next annual review of the Child Core Set with the appointment of a new,
multistakeholder Medicaid Child Workgroup. The results are due to CMS by the end of August 2018.
Promoting Integrated and Coordinated Care that Addresses Social Risk for the Dual Eligible
Beneficiary Population37
Dual eligible beneficiaries are a growing population with complex needs that require high levels of
services and supports. 38 Dual eligible beneficiaries comprise 20 percent of Medicare beneficiaries but
account for 34 percent of annual spending, at approximately $187 billion. Similarly, dual eligible
beneficiaries comprise 15 percent of Medicaid beneficiaries but account for 33 percent of annual
spending at approximately $119 bHJion. 39 NQF's Dual Eligible Workgroup was established six years ago
to address the unique challenges of caring for the nation's most vulnerable population. The Workgroup
identified a core set of healthcare quality measures for this population, the Dual Eligible Beneficiaries
Family of Measures (the Family of Measures), which it has annually reviewed and updated. The 2017
Family of Measures contained 71 healthcare quality measures. The Starter Set, a subset of the Family of
Measures that addresses critical clinical issues for the dual eligible population, contained 16 measures.
In its 2017 review of the Family of Measures, the Workgroup recommended the addition of measures
addressing functional change, hospital discharges to community settings, patients' feedback about the
quality of long-term services received in a community setting, and population-level HIV viral load
suppression. The Workgroup supported the removal of eight measures from the Family of Measures
because they are no longer NQF-endorsed.
The Workgroup discussed the need for better coordination and integration of efforts to include various
stakeholders, such as federal agencies and community organizations, along with effective use of
available measurement tools. To accomplish these objectives, the Workgroup recommended that HHS
develop a collaboration strategy for federal agencies and work with community-based organizations.
The Workgroup discussed the need for a paradigm shift in measure conceptualization and development.
Workgroup members suggested that future measure development should start at the individual
beneficiary level to address the population's needs and gap areas. The Workgroup also encouraged
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measurement that has an expanded focus on quality, for example, to help connect medical and social
care.
The Workgroup emphasized the need for a population-based measurement framework that recognizes
and measures the effects of social risk factors on health outcomes. The Workgroup identified l1 social
risk factors that underscore the complexity of the dual eligible population, including social support,
residential and community context, and socioeconomic position, status, and income.
HHS has not funded NQF in 2018 to review the Family of Measures. However, NQF will continue its
efforts to improve the quality of care for vulnerable individuals by incorporating the needs of dual
eligible beneficiaries across all of its work, including measure review and endorsement, review of
Medicaid core measure sets, and the work of its Disparities Standing Committee. NQF also will continue
to explore opportunities to re-engage the Duals Workgroup in the future.
111.
Quality and Efficiency Measurement Initiatives (Performance Measurement)
Section 1890(b}{2) and (3) of the Social Security Act requires the consensus-based entity (CBE) to endorse
standardized hea/thcare performance measures. The endorsement process must consider whether
measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes,
actionable at the caregiver level, feasible for collecting and reporting, responsive to variations in patient
characteristics, and consistent across types of healthcare providers. In addition, the CBE must establish
and implement a process to ensure that measures endorsed are updated (or retired if obsolete) as new
evidence is developed. 40
Working with multistakeholder committees to build consensus, NQF reviews and endorses healthcare
performance measures. 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 improvement
efforts. The federal government, states, and private-sector organizations use NQF-endorsed measures
to evaluate performance; inform employers, patients, and their families; and drive quality improvement.
Together, NQF-endorsed measures serve to enhance healthcare value by ensuring that consistent, highquality performance data are available, which allows for comparisons across providers as well as the
ability to benchmark performance. Currently, NQF has a portfolio of 628 NQF-endorsed measures.
Subsets of this portfolio apply to particular settings and levels of analysis.
Important Changes to NQF Measure Endorsement
NQF is committed to making measure endorsement more efficient, fostering innovation, and enabling
greater access to NQF's technical assistance.
NQF's measure endorsement process, also referred to as the Consensus Development Process (CDP),
provides the nation, including HHS' public reporting and pay-for-performance initiatives, with a portfolio
of measures that meet rigorous evaluation criteria and that are reflective of the current evidence,
reliable and valid, useful for accountability and quality improvement, and feasible to implement.
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Since NQF approved the first version of the COP in July 2000, NQF has continuously refined its process to
address the needs of the healthcare industry. Many of these refinements have been incremental and
others more substantive, requiring pilot testing and significant operational changes. With CMS funding,
NQF hosted its most recent process improvement event May 18-19,2017, which involved thoroughly
examining how NQF endorses measures, specifically to make the process more agile and reduce the
cycle time for measure submission and review. More than 40 private- and public-sector stakeholdersincluding experts from CMS and other federal agencies, members of NQF standing committees, and
representatives of organizations that develop measures-also provided input, as did NQF members and
the public. The resulting changes are outlined in the 2017 Consensus Development Process Redesign 41
report.
Increased Opportunities for Measure Submission
Among the most significant changes is that NQF standing committees can now evaluate measures for
endorsement twice a year. Previously, standing committees reviewed a select few new and current
measures each year, contingent on funding. With this change to more frequent endorsement review,
NQF aims to reduce standing committee downtime and be more responsive to the rapidly evolving
healthcare system. However, NQF now limits the number of measures that may be evaluated by its
standing committees in one measure review cycle to a maximum of 12, including up to eight measures
undergoing maintenance review and up to four measures being evaluated for initial endorsement.
limiting the number of measures reviewed in a cycle ensures that the standing committees have the
capacity to provide each measure with a thorough, efficient, and rigorous review.
Consolidated Measure Review Topical Areas
To optimize the evaluation of NQF's library of measures, NQF consolidated or modified some of its
committees. These modifications help to balance measure portfolios and grouped cross-cutting clinical
areas, such as Primary Care and Chronic Illness and Geriatrics and Palliative Care. NQF's measure
portfolio now comprises 15 topical areas, including:
•
•
•
All-Cause Admissions/Readmissions
Behavioral Health and Substance Use
Cancer
•
•
Cardiovascular
.
Cost and Efficiency
•
•
Neurology
•
•
Pediatrics
•
•
•
•
•
Geriatric and Palliative Care
Patient Experience and Function
Patient Safety
Perinatal and Women's Health
Prevention and Population Health
Primary Care and Chronic tllness
Renal
Surgery
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Individual standing committees will no longer convene for the following topical areas: Person- and
Family-Centered Care; Ears, Eyes, Nose, and Throat Conditions; Endocrine; Musculoskeletal; Infectious
Diseases; Care Coordination; Gastrointestinal; and Genitourinary.
Intent to Submit
NQF now requires measure developers and stewards to submit measure specifications and testing
information along with an Intent to Submit form at least three months prior to the measure submission
deadline. This advance notification will allow NQF to adequately plan for measures in the pipeline and
maintenance measures ready for re-evaluation in the various topic areas. NQF also encourages measure
developers to seek technical assistance from NQF staff during this time.
Technical Review: NQF Scientific Methods Panel
In September 2017, NQF established the Scientific Methods Panel (SMP) {see~~~~~ to assist in
conducting methodological reviews of measures being reviewed for endorsement. The Panel's creation
was in response to feedback from key stakeholders who took part in NQF's 2017 process improvement
event. These stakeholders noted the challenges many standing committee members face conducting
technical reviews of measures when their background is not in statistics or measure development.
Stakeholders recommended that NQF shift the responsibility of scientific review of measures from the
committees to an SMP and NQF staff. Their intent was to allow consumers, patients, purchasers, and
other members of NQF standing committees to focus on bringing their expertise to the subject matter
under consideration and to be more engaged throughout the evaluation process.
The SMP consists of 24 individuals with methodological expertise. Panel members are appointed to an
initial two- or three-year term, with an optional three-year term to follow. NQF issues a transparent and
public call for nominations from statisticians, epidemiologists, psychometricians, economists,
performance measure methodologists, and experts in eMeasures as well as disparities in healthcare
who also have relevant knowledge and/or proficiency in methodology, implementation of measures,
and/or broad clinical expertise that would lend itself to the evaluation of complex measures. After a
public comment period. of the proposed SMP roster, NQF senior leadership approved the Panel slate.
The SMP conducts evaluations of scientific acceptability for selected, complex measures. Specifically, the
SMP reviews the "must-pass" subcriteria of reliability and validity using NQF's standard measure
evaluation criteria 42 for new and maintenance measures. The SMP provides a preliminary
recommendation to NQF staff and the standing committees. NQF staff will continue to provide a
preliminary analysis of all measures under review, including a methods review for noncomplex
measures. The following measures are considered complex and may require an evaluation by the SMP:
•
Outcome measures, including intermediate clinical outcomes
•
Instrument-based measures (e.g., patient-reported outcome performance measures)
•
Cost/resource use measures
•
Efficiency measures (those combining concepts of resource use and quality)
•
Composite measures
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In addition to evaluating submitted measures for scientific acceptability in NQF's measure endorsement
process, the SMP will serve in an advisory capacity to NQF on methodologk issues related to measure
testing, risk adjustment, and measurement approaches. As measures have become more complex, a
myriad of issues have emerged related to me'asure testing, data sources, and assessment of reliability
and validity. The Panel will help to ensure that NQF's testing requirements adjust to changes in
measurement science.
Additional Changes
Expanding the measure evaluation commenting period for the public and NQF members to 15+
consecutive weeks. NQF will have one continuous public commenting period for measures under
review. Reflecting NQF's commitment to transparency, this expanded commenting period replaces two
separate commenting periods (a 14-day pre-meeting comment period and 30-day post-meeting
comment period). Standing committees will review all submitted comments, and all submitted
comments will receive a written response from the standing committee, measure developer or steward,
or NQF staff, as appropriate.
Allowing only NQF members to signal support for measures under review. Process improvement event
participants recommended that NQF members should no longer vote on measure endorsement
decisions during a separate 15-day voting period to inform standing committees' recommendations.
NQF members can now express their support ('Support' or 'Do Not Support') for measures during the
15+ week continuous public commenting period. This opportunity for NQF members to express
support/nonsupport for measures is intended to promote and facilitate their engagement and feedback
in the endorsement process.
Simplifying the structure and content of NQF measure evaluation reports. These changes are intended
to minimize the length and density of technical reports on measure evaluations. Reports will be
streamlined to include an executive summary that indicates the endorsement decision, brief summaries
of each measure reviewed, details of committee deliberations on each measure against NQF measure
evaluation criteria, and full measure specifications. In addition, NQF will create an annual cross-cutting
report across all the topic areas that will summarize trends and performance, high-priority gap areas in
measurement for future development, and measure concepts submitted during the solicitation process
for measures.
Enhancing education and training for stakeholder participation and engagement. NQF will expand and
strengthen the current range of educational resources offered to specific audiences, including
committee members, developers, and staff. Feedback received from participants in NQF's process
improvement activity mentioned the need for more accessible and tailored resources for stakeholders
engaged at various points of the CDP. In response, NQF will develop more on-demand, virtual, education
resources that provide technical and other assistance. These and other recommendations to enhance
stakeholder education and training are being implemented through a phased process and timeline that
began in the summer of 2017.
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Improving access to and exchange of measure information between the measure endorsement
process and the Measure Applications Partnership (MAP). Process improvement event participants
noted that there is significant overlap between NQF's two separate review processes {measure
endorsement through the COP and input on measure selection and use through MAP) and called for a
centralized resource to access comprehensive and longitudinal information on measures. NQF is
advancing initiatives to aggregate data from MAP reviews on measure selection and use as well as to
consolidate existing information from endorsement review reports to make it easier for users to access
measure information.
Future, additional and strategic changes may be implemented to the NQF COP with direction from NQF's
Consensus Standards Approval Committee (CSAC) and Board of Directors. For example, process
improvement participants recommended changing how final endorsement decisions are made.
Specifically, they recommended that standing committees, not NQF's Consensus Standards Approval
Committee {CSAC), 43 make final endorsement decisions without ratification from the CSAC. Their
rationale was that the CSAC rarely overturns standing committee measure endorsement
recommendations. Additionally, process improvement participants recommended that the CSAC, and
not the NQF Appeals Board, adjudicate appeals of decisions to endorse or not endorse measures. Given
important strategic considerations, NQF will assess the newly designed COP over time to determine
whether these changes will enhance the process during future iterations.
Cross-Cutting Project to Improve the Measurement Process
In 2017, NQF's measurement science work continued to advance understanding of attribution and
potential best practices in quality reporting and value-based payment models. Attribution is the
methodology used to assign patients, and the quality or costs of their healthcare, to specific
organizations or providers.
As healthcare payers and consumers increasingly seek greater value from healthcare services,
determining which physicians or other providers are ultimately responsible for the quality and outcomes
of the care patients receive is paramount. Attribution models are essential parts of policy and program
design as well as measure development and implementation. Currently, a wide range of such models are
in use across the nation, and, in some cases, limited information about the specifics of these models
exists. The lack of standardization and specificity has prompted concerns from providers and other
accountable entities that some models may inaccurately assign accountability for patients or outcomes.
in its role as the CBE, NQF continues its work to address these issues, which are fundamental to
achieving a value-based healthcare system. In work that began September 2017, NQF has convened a
multistakeholder advisory panel to build on the foundational guidance provided in NQF' s 2016 report on
attribution and its accompanying Attribution Model Selection Guide. The goal for the new work of the
Improving Attribution Models Advisory Panel is to address notable attribution challenges, including the
development and selection of attribution models to link health outcomes or costs to individual providers
or teams of providers that include nonclinidans and care for patients with complex medical needs. The
Panel also will share guidance on evaluating attribution models for health outcomes among specific
patient populations, including pediatric patients or those with comorbidities. The Panel also will weigh in
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on the role of attribution for NQF's measure endorsement and Measure Applications Partnership
processes. A final report with the Panel's recommendations is expected in August 2018.
Social Risk Trial
Value-based purchasing and alternative payment models aim to reduce healthcare spending while
improving quality by tying provider payments to performance on cost and quality measures (e.g.,
readmission rates, complication rates, or mortality rates). HHS has stated a goal to tie 90 percent of
Medicare fee-for-service payments to performance on quality measures by the end of 2018. 44 CMS
operationalizes this goal through federal accountability programs such as the Merit-Based Payment
System, Hospital Readmissions Reduction Program, and Hospital Value-Based Purchasing Program.
Public- and private-sector payers also are increasingly using outcome measures as the performance
metrics in value-based purchasing programs. However, healthcare outcomes are not solely the result of
the quality of care received and can be influenced by factors outside a provider's control, such as a
patient's comorbid conditions or severity of 111ness. Because patients are not randomly assigned to
providers, performance measures should account for these underlying differences in patients' health
risk to ensure performance measures make fair conclusions about provider quality. Risk adjustment
(also known as case-mix adjustment) refers to statistical methods to control or account for patientrelated factors when computing performance measure scores.
Risk adjusting outcome measures to account for differences in patient health status and clinical factors
(e.g., comorbidities, severity of illness) that are present at the start of care is widely accepted. However,
there is a growing evidence base that a person's social risk factors (i.e., socioeconomic and demographic
factors) can also affect health outcomes. 45 Previous NQF policy did not a11ow for measure developers to
include social risk factors in the risk-adjustment models of measures being submitted for NQF review
and endorsement This policy was developed because of concerns that including these factors in the
risk-adjustment models of endorsed measures could mask disparities or create lower standards of care
for people with social risk factors. However, the increased use of performance measures for public
reporting and payment purposes underscores the need to ensure that these measures fairly and
accurately assess quality. As a result, stakeholders and policymakers have called for the federal
government to examine impact of social factors on the results of performance measures.
In August 2014, an NQF-convened Expert Panel recommended that NQF allow the inclusion of social risk
factors in the risk-adjustment models of endorsed measures where there is both a conceptual basis (i.e.,
a logical theory or rationale) and empirical evidence that show social risk factors can influence the
outcomes assessed in the measures. The Expert Panel also recommended that performance measures
adjusted for social risk be stratified by social and demographic factors to identify disparities. However,
concerns remained about the appropriateness and feasibility of allowing NQF-endorsed measures to be
adjusted for social risk. To address these concerns, the NQF Board of Directors suspended NQF's policy
prohibiting the inclusion of social risk factors in risk-adjustment models and instituted a two-year trial to
assess how and when it is appropriate to adjust performance measures for social risk. NQF's Disparities
Standing Committee provided oversight and guidance on the evaluation of the results of the trial.
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In April2017, NQF concluded this self-funded two-year trial period during which measure developers
were required to explore the impact of social risk factors on the results of their measures and could
include social risk factors in the risk-adjustment models of measures submitted for endorsement review
if there was a conceptual basis and empirical evidence to support doing so. NQF' s work, as well as
and the Office of
risk factors affect their health and healthcare.
The trial period included all measures submitted for review from April 2015 through April2017. During
this two-year period, NQF reviewed 303 performance measures across 16 topical areas. Out of the 303
measures submitted for endorsement, 93 included some form of risk adjustment. The measure
developers found-and the standing committees reviewing these measures agreed-that 65 of these 93
risk-adjusted measures had a conceptual basis for including social risk factors in the model. This
relationship was demonstrated empirically for 21 out of these 65 measures. Ultimately, 17 out of these
in their risk-adjustment model.
21 measures were
The trial period highlighted challenges to adjusting measures for social risk factors. First, the trial
revealed challenges in obtaining data on social risk factors, including data granular enough to reflect
individuals' social risk accurately. Next, the trial found that social risk factors had variable impacts on
performance scores, reaffirming the Expert Panel's guidance that each measure must be assessed
individually to determine if there is an empirical basis for social risk factor adjustment. In July 2017, NQF
issued a report of its findings 48 from the trial, highlighting key conclusions and areas where further study
may be needed.
Throughout the trial period, stakeholders expressed varying views on whether or not including social risk
factors would worsen healthcare disparities. Some stakeholders reiterated concerns about masking
disparities or creating different standards of care. However, others cautioned that using measures that
are not adjusted for social risk factors for payment purposes disproportionately penalizes safety-net
provides and could worsen disparities by threatening access to care.
To allow for monitoring of potential disparities in care, NQF requires the developers of measures that
include social risk factors in their risk-adjustment models to also submit specifications to calculate a
version ofthe measure that only includes clinical risk factors and which can be stratified by social risk.
This would allow measure users to compare the measure when adjusted for social risk and when only
adjusted for clinical risk to better understand the effects of adjustment for social risk.
In July 2017, the NQF Board of Directors approved
a three-year extension of the policy allowing measure
developers to include social risk factors in risk-adjustment models for outcome measures submitted for
endorsement. NQF staff will review the risk-adjustment approach during the preliminary analysis of
each measure. Additionally, NQF's Scientific Methods Panel 49 will review all outcome measures and
provide guidance on the appropriateness of the risk-adjustment methods. NQF standing committees will
continue to review the conceptual basis and the appropriateness of social and clinical risk factors
included in each measure's risk-adjustment model.
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Current State of NQF Measure Portfolio: Responding to Evolving Needs
Working with multistakeholder committees, 50 NQF maintains its endorsed measure portfolio to keep it
relevant. This maintenance may include removing endorsement for measures that no longer meet
rigorous criteria, facilitating measure harmonization among competing or similar measures, or retiring
measures that no longer provide significant opportunities for improvement. NQF encourages measure
developers to submit measures that can drive more meaningful improvements in care, such as measures
of patient-reported outcomes. While NQF pursues strategies to make its measure portfolio
appropriately lean and responsive to real-time changes in evidence, it also proactively seeks measures
from the field that will help to fill known measure gaps and that align with the NQS goals.
NQF worked on 18 quality measure endorsement projects in 2017. Across these HHS-funded
endorsement projects, NQF endorsed 120 measures and removed 109 measures from its portfolio.
NQF's measure portfolio contains high-value measures across a variety of clinical and cross-cutting topic
areas. Forty-two percent of the measures in NQF's portfolio are outcomes measures. NQF's
multistakeholder committees-which include providers, payers, and other experts from across
healthcare, as well as patients and consumers-review both previously endorsed and new measures
using rigorous evaluation criteria. The committees make recommendations for NQF to endorse or not
endorse measures. In 2017, NQF's Board completed its service as the ratifying body for endorsement
decisions of the CSAC. The CSAC now makes all final endorsement decisions.
Measure Endorsement and Maintenance Accomplishments
All measures are evaluated by subject matter and measurement expert committees against the
following NQF criteria:
1. Importance to Measure and Report
2.
Reliability and Validity- Scientific Acceptability of Measure Properties
3.
Feasibility
4.
Usability and Use
5.
Comparison to Related or Competing Measures
More information is available in the Measure Evaluation Criteria and Guidance for Evaluating Measures
for Endorsement. 51
~ndix
A lists the types of measures reviewed in 2017 and the results of the review. Below are
summaries of endorsement and maintenance projects completed in 2017, as well as projects that began
but were not completed during the year.
Completed Projects
All-Cause Admissions and Readmissions
High rates of readmissions are costly to the healthcare system and can indicate low-quality care during a
hospital stay and poor-quality care coordination. Unnecessary hospitalizations can prolong the illness of
patients, increase their time away from home and family, expose them to potential harms, and add to
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their costs. A 2013 Medicare Payment Advisory Commission (MedPAC) report suggests that reducing
avoidable readmissions by 10 percent could achieve a savings of $1 billion or more. 52
Successful efforts to drive down readmissions are being applied beyond inpatient hospital stays to postacute care settings and across the entire continuum of care. 53•54 NQF currently has 47 endorsed all-cause
and condition-specific admissions and readmissions measures addressing numerous settings. Many of
these measures are used in various private and federal quality reporting and value-based purchasing
programs, including CMS' Hospital Readmission Reduction Program {HRRP).
NQF undertook two projects to review admissions and readmissions measures in 2017. The first phase
began in 2015. The Board of Directors finalized the endorsement decisions of measures in this first
phase in December 2016. However, because NQF received appeals of the endorsement decision for
some measures, the project did not conclude until April 2017. NQF considers an endorsement project
complete after adjudication of any appeals received and issuance of the final report.
During the 2015-2017 phase of work, NQF's All-Cause Admissions and Readmissions Standing
Committee evaluated 11 new measures and six measures undergoing maintenance review. Sixteen
measures were endorsed, and one was not endorsed. Endorsed measures assessed issues such as
hospitalization and emergency department use from home health settings and 30-day readmissions for
various conditions. These measures were included in NQF's groundbreaking trial to determine whether
NQF should permanently change its policy and allow measures to be adjusted for social risk factors.
Ultimately, one measure, NQF 112858 Discharge to Community, was found to have both a conceptual
basis and empirical evidence to adjust the measure for social risk. One social risk factor, marital status,
was included in the risk-adjustment model of this measure. This project phase concluded in April2017.
In the most recent 2017 phase of work, the Committee evaluated two additional measures. Both
measures were endorsed. One of these measures, which assesses unplanned readmissions for cancer
patients, was endorsed with one social risk factor in its risk-adjustment model (dual eligibility for
Medicare and Medicaid). This project phase concluded in September 2017.
Behavioral Health
About 43.8 million people in the United States-nearly one in five-experience a mental illness in a
given year. 55 In addition, 20.2 million U.S. adults had a substance use disorder, of which SO.S percent
had both a mental disorder and a substance use disorder. 56 In 2013, the United States spent $201
billion for mental healthcare, and that number is expected to continue risingY Given the extent and
impact of mental illness and substance use disorders, performance measurement in this area needs to
remain operational and current.
This multiphase project endorsed measures for improving the delivery of behavioral health services,
achieving better behavioral health outcomes, and improving the behavioral health of the U.S.
population, especially those with mental illness and substance abuse. Prior phases of this project
concluded with endorsement of 46 measures. NQF's behavioral health portfolio currently contains 54
measures.
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in the 2016-2017 project phase, NQF's Behavioral Health Standing Committee examined measures of
tobacco use, alcohol and substance use, attention deficit hyperactivity disorder (ADHD), depression,
medication continuation and reconciliation, and follow-up after hospitalization for mental illness. The
Committee evaluated seven new measures and six measures undergoing maintenance review. Nine
measures were endorsed, three were not endorsed, and one measure undergoing maintenance review
was deferred for future, continued endorsement consideration. This project concluded in August 2017.
Cancer
Cancer is the second most common cause of death in the United States, exceeded only by heart
disease. 58 The National Cancer Institute estimates that 595,690 people died from cancer in 2016. 59
Nearly half of all men and one-third of all women in the U.S. will develop cancer during their lifetime/50
The National Cancer Institute estimated that in 2010 the costs for cancer care in the United States
totaled nearly $157 billion and could reach $174 billion in 2020. 61
The complexity of cancer and the many care settings and providers involved in its treatment underscore
the need for quality measures that address the value and efficiency of care for patients and their
families. NQF's portfolio of 34 cancer measures includes measures for breast cancer, colon cancer,
hematology, lung and thoracic cancer, prostate cancer, and other general cancer measures. These
measures address cancer screening, appropriate treatment (including surgery, chemotherapy, and
radiation therapy), and morbidity and mortality.
NQF's Cancer Standing Committee evaluated three new measures and 15 measures undergoing
maintenance review. Thirteen measures were endorsed, two measures received inactive endorsement
with reserve status, and three measures were not endorsed. The purpose of inactive endorsement with
reserve status is to retain endorsement of reliable and valid quality performance measures that have
overall high levels of performance with little variability, so that performance may be monitored as
necessary to ensure that it does not decline. This project concluded in January 2017.
Cardiovascular
Cardiovascular disease (CVD) is the leading cause of death in the United States. It kills nearly one in four
Americans and costs $312 billion per year, more than 10 percent of annual health expenditures. 62
Considering the overall toll of cardiovascular disease, measures that assess clinical care performance
and patient outcomes are paramount to reducing the negative impacts of CVD.
This multiphase project has built up a portfolio of 54 cardiovascular measures, covering primary
prevention and screening, coronary artery disease (CAD), ischemic vascular disease (IVD), acute
myocardial infarction (AMI), cardiac catheterization, percutaneous catheterization intervention (PC I),
heart failure (HF), rhythm disorders, implantable cardioverter-defibrillators (ICDs), cardiac imaging,
cardiac rehabilitation, and high blood pressure.
In the 2016-2017 project phase, NQF's Cardiovascular Standing Committee evaluated two new measures
and four measures undergoing maintenance review. Four measures were endorsed, and two were not
endorsed. One of the endorsed measures, NQF #0076 Optimal Vascular Care, included a social risk
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factor, status and type of insurance, in its risk adjustment model. This project concluded in February
2017.
Care Coordination
The coordination of care is essential to reduce preventable hospitalizations, achieve better patient
outcomes, and lower costs in today's healthcare system. Reducing preventable hospitalizations is a
significant factor in controlling healthcare costs. 63 In 2010, preventable hospital admissions accounted
for nearly $32 billion in costs for adults with selected chronic and acute diseases. 54
This multiphase project focused on healthcare coordination across episodes of care and care transitions.
The NQF portfolio for care coordination includes 14 measures, covering emergency department
transfers, plan of care, e-prescribing, timely transitions, medication management, and transition
records.
In the 2016-2017 project phase, NQF's Care Coordination Standing Committee evaluated two new
measures and five measures undergoing maintenance review. One measure was endorsed, and six were
not endorsed. Endorsement was removed from four previously endorsed measures. This project
concluded in August 2017.
Cost and Resource Use
In 2015, healthcare spending in the United States reached $3.2 trillion-a 5.8 percent increase over
2014 spending, 65 but the United States continues to rank below other developed countries for health
outcomes, including lower life expectancy and greater prevalence of chronic diseases. 66 The United
States is also falling behind other developed countries in the quality domains of effective care, safe care,
coordinated care, and patient-centered care. 67 1mproving efficiency has the potential to simultaneously
reduce the rate of cost growth and improve the quality of care provided.
The NQF cost and resource use portfolio includes six measures. The 2016-2017 project was the latest
phase of NQF's work on evaluating and endorsing cost and resource use measures, initially begun in
2010. The prior three phases of work focused on the evaluation of both condition-specific and
noncondition-specific measures of total cost, using per capita or per hospitalization episode approaches.
In this fourth phase, NQF's Cost and Resource Use Standing Committee evaluated three existing
noncondition-speciftc measures of cost and resource use. All three measures received continued
endorsement. These measures were included in NQF's social risk trial; therefore, the measure
developers were asked to evaluate the impact of social risk factors on the outcome of their measures.
The developers of all three measures found a conceptual basis to potentially include social risk factors in
the risk·adjustment models of their measures. However, when these factors were tested empirically,
their inclusion did not significantly improve the performance of the risk-adjustment model and did not
result in statistically significant changes in measure scores for nearly all providers. As a result, these
measures were not endorsed with adjustment for social risk. This project concluded in August 2017.
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Eye Care and Ear, Nose, and Throat Conditions
More than 3.4 million (3 percent) of Americans 40 years of age or older are either blfnd or visually
impaired, and millions more are at risk for developing vision impairment and blindness. 68 At
a cost of
$139 billion in 2013, eye disorders and vision loss are among the costliest health conditions currently
facing the United States. 69 Hearing loss affects 1 in 10 Americans. In 2010, there were an estimated 20
million visits to otolaryngologists in America, and one-fifth of these visits were made by people under
age 15. 70
NQF's Eye Care, Ear, Nose, and Throat (EENT) Standing Committee identifies and endorses measures in
areas related to glaucoma, macular degeneration, cataracts, hearing screening and evaluation, and ear
infections. The NQF EENT measure portfolio includes 21 measures. In 2017, the Committee evaluated
two new measures. One measure was endorsed, and the other was not endorsed. This project
concluded September 2017.
Health and Well-Being
Medical care has a relatively small influence on overall health when compared with behaviors such as
smoking and poor diet, physical environmental hazards, and social factors like low educational
achievement and poverty. 71 Social, environmental, economic, and behavioral factors all play a significant
role in maintaining and improving health and well·being. These and other determinants of health
contribute to up to 60 percent of deaths in the United States, 72 yet less than 5 percent of health
expenditures target prevention. 73
The NQF health and well·being portfolio includes 47 measures, which cover areas such as health-related
behaviors to promote healthy living; community-level indicators of health and disease; modifiable social,
economic, and environmental determinants of health; primary prevention and/or screening; and oral
health.
In 2017, NQF's Health and Well-Being Standing Committee evaluated 12 new measures and 11
measures undergoing maintenance review. The 2017 project was the third phase of NQF's work to
review measures focused primarily on primary prevention and/or screening. Ultimately, 13 measures
were endorsed, one measure received inactive endorsement with reserve status, and six measures were
not endorsed. Three eMeasures assessing hepatitis C screening for at-risk patients, as well as
appropriate follow-up, were approved far trial use. The trial use designation allows the eMeasures that
are ready for implementation to undergo the reliability and validity testing necessary for full
endorsement consideration by using clinical data in electronic health records (EHRs). Measures
approved for trial use may be submitted for endorsement review within three years. NQF's health and
well-being project concluded in April 2017.
Infectious Disease 2016-2017
Each year, the nation spends more than $120 billion to treat infectious diseases and $5 billion to treat
antibiotic resistant bacteria. 74 Infectious diseases account for 3.9 million hospital visits per year and are
a leading cause of death in the United States. 75 Septicemia is the most expensive condition treated in
U.S. hospitals, costing $20.3 biliion in 2011. 76
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The NQF infectious disease portfolio includes nine measures. In its 2017 work, NQF's Infectious Disease
Standing Committee evaluated measures that address infectious diseases, such as HIV/AIDS and sepsis,
and made recommendations for measure endorsement. The project built on NQF's earlier work to set
performance measurement standards for HIV/AIDS and other sexually transmitted infections, hepatitis,
adult and pediatric respiratory infections, and sepsis.
The Committee evaluated four new measures and five measures undergoing maintenance review. All
nine measures were endorsed. This project concluded in August 2017.
Musculoskeletal
Musculoskeletal disorders (MSDs) are a leading cause of disability in the United States, with increasing
prevalence and cost associated with musculoskeletal diseases in an aging population. 77 In addition to
the morbidity associated with musculoskeletal disorders, there has been a significant increase in costs to
treat musculoskeletal disorders. 78 Low back pain is among the most common reasons for visits to
physicians and a major reason for work-related disability. Because of the burden of these disorders,
there is a critical need for nationally recognized musculoskeletal care measures.
1
The NQF musculoskeletal portfolio includes 29 measures. In Its 2016-2017 work, NQF S Musculoskeletal
Standing Committee evaluated two measures undergoing maintenance review. Neither measure was
endorsed. This project concluded in July 2017.
Palliative and End-of-Life Care
Improving both access to, and quality of, palliative and end-of-life care is becoming increasingly
important due to the aging of the U.S. population; the projected increases in the number of Americans
with chronic illnesses, disabilities, and functional limitations; and the growth in ethnic and cultural
diversity, which has intensified the need for Individualized, person-centered care. 79
The NQF palliative and end-of-life portfolio includes 59 measures. In 2017, NQF's Palliative and End-oflife Standing Committee evaluated a new composite measure assessing whether hospices perform
seven critical care processes upon admission of adult patients. Seven individual NQF-endorsed quality
measures-which are currently implemented in the CMS Hospice Quality Reporting Program-will
provide the source data for this comprehensive assessment measure. The measure was endorsed.
The Standing Committee in 2017 also made several refinements to NQF's measurement framework for
palliative and end-of-life care. For example, the Standing Committee differentiated curative palliative
care, which is provided alongside curative treatment, and chronlc palliative care, which is provided to
individuals with noncurable conditions who are not near the end of life. The Standing Committee also
emphasized the need for measurement focused on the caregiver, among other recommendations. This
project concluded in September 2017.
Patient Safety
Errors and adverse events associated with healthcare cause hundreds of thousands of preventable
deaths each year in the United States. 80 Patient safety-related events occur across healthcare settings
from hospitals to clinics to nursing homes and include healthcare-associated infections {HAis),
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medication errors, falls, and other potentially avoidable occurrences. The societal costs are tremendous.
These costs include higher use of hospital and other services, higher insurance premiums, higher taxes,
lost work time and wages, and reduced quality of life.
NQF-endorsed patient safety measures are important tools for tracking and improving patient safety
performance in U.S. healthcare. NQF's patient safety portfolio includes 73 measures, including measures
of medication safety, healthcare-associated infection, falls, pressure ulcers, and other safety concerns.
These measures are used in many quality improvement, public reporting, and accountability programs
across the country. Federal programs using measures from NQF's patient safety portfolio include CMS'
Physician Quality Reporting System (PQRS), and the Hospital Inpatient Quality Reporting (IQR} Program,
Hospital Value-Based Purchasing (VBP) Program, and the Hospital-Acquired Condition Reduction
Program (HACRP).
In a project that concluded in March 2017, NQF's Patient Safety Standing Committee evaluated 13 new
measures and two measures undergoing maintenance review. Eleven measures were endorsed and two
measures were not endorsed. The endorsement decision for one measure undergoing maintenance
review was deferred. In addition, one eMeasure to assess the quality of blood samples in the emergency
department was approved for trial use. The endorsed measures include three measures to address the
prescription of opioids at high doses or from multiple providers, with appropriate exclusions, including
cancer patients. These are the first NQF-endorsed measures intended to address the nation's
devastating-and growing-opioid epidemic.
In a separate project that concluded in July 2017, the Committee evaluated the deferred measure from
its March 2017 work, as well as six new measures. The deferred measure, which is part of the
Healthcare Effectiveness Data and Information Set (HEDIS) and assesses whether or not older adults
were dispensed a high-risk medication, was endorsed. The Committee evaluated the six new measures,
which were intended to assess potentially avoidable complications for patients with certain conditions.
The measure developer withdrew the measures from further consideration before NQF made a final
endorsement decision.
Pediatric
Approximately 74 million children under 18 years of age live in the United States, representing 23.3
percent ofthe population. 81 The number of children and adolescents diagnosed with chronic medical
conditions has risen consistently over the last decades.81 Although the number of NQF-endorsed
pediatric measures to evaluate and improve care of children and adolescents is growing, expanding the
availability of evidence-based pediatric measures for public and private use is a priority.
The Children's Health Insurance Reauthorization Act of 2009 (CHIPRA) accelerated interest in pediatric
quality measurement and provided an unprecedented opportunity to improve the healthcare quality
and outcomes of the nation's children, especially the nearly 36 million children enrolled in Medicaid
and/or CHIP 8 '- CHIPRA mandates that CMS develop and update a core set of performance measures for
voluntary use by states to assess the quality of care provided to children enrolled in Medicaid and
CHIP-the Child Core Set-and requires annual recommended updates to the set.
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NQF's pediatrics portfolio includes 102 measures, of which 39 are specific to the pediatric population
and 63 include both the pediatric and adult populations. Many of the measures in the pediatric portfolio
are in use in at least one federal program. Seventeen NQF-endorsed measures were included in the
2017 Core Set of Children's Health Care Quality Measures for Medicaid and CHIP (Child Core Set). 84
For this project, which concluded in August 2017, NQF's Pediatric Standing Committee evaluated 11 new
measures. Four measures were endorsed, including a new facility-level outcome measure of preventable
adverse events among pediatric inpatients, as well as an outcome measure to examine public insurance
participation rates and measure continuity of enrollment among vulnerable children. Seven measures
were not endorsed.
Person- and Family-Centered Care
Ensuring that patients and their families are engaged partners in care is one of the core priorities of the
NQS and is a focus of significant healthcare efforts. NQF's person- and family-centered care (PFCC)
portfo!lo has 62 measures, most of which are outcome measures. The portfolio includes measures
focused on quality of life, functional status, experience of care, shared decision making,
symptom/symptom burden, and communication.
In the phase of PFCC work that concluded in January 2017, NQF's PFCC Standing Committee evaluated
12 new measures and one measure undergoing maintenance review. All13 measures were endorsed,
including patient-reported outcome (PRO) performance measures.
Renal
Renal disease is a leading cause of death and morbidity in the United States. Millions of Americans have
chronic kidney disease (CKD), and over half a million Americans have received a diagnosis of end-stage
renal disease (ESRD), the only chronic disease covered by Medicare for people under the age of 65. ss
NQF's renal portfolio currently contains 21 measures. For this project, which began in 2015 and
concluded in February 2017, NQF's Renal Standing Committee evaluated three new measures and three
measures undergoing maintenance review. Five measures were endorsed, including measures to assess
hemodialysis patients. One measure was not endorsed. Of the five endorsed measures, one was
endorsed with adjustment for social risk.
Surgery
The rate of surgical procedures continues to increase annually, and ambulatory surgery centers are the
fastest growing provider type participating in Medicare. 86 Performance measurement and reporting
provide an opportunity to further improve the safety and quality of surgical care.
NQF's surgery measure portfolio is one of its largest, with 62 measures. It addresses cardiac, vascular,
orthopedic, urologic, and gynecologic surgeries, and includes measures for adult and child surgeries as
well as surgeries for congenital anomalies. The portfolio also includes measures of perioperative safety,
care coordination, and a range of other clinical or procedural subtopics. Many of the measures in the
portfolio are used in public- and/or private-sector accountability and quality improvement programs.
However, while significant strides have been made in some areas, measure gaps remain for some types
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of procedures and additional, effective measures are needed to evaluate and improve overall surgical
quality, shared accountability, and patient-centered care.
During the 2015-2017 phase of work, NQF's Surgery Standing Committee evaluated 10 new measures,
including five new eMeasures, and 13 measures undergoing maintenance review. Fifteen measures
were endorsed, three were not endorsed, and the five eMeasures were not approved for trial use.
New Projects in 2017
In September 2017, NQF began work to review measures in 14 topic areas. This work will be completed
under NQF's new, compressed endorsement process which now allows for two measure review cycles
annually. Measure developers may submit measures for endorsement review for the cycle initiated in
September 2017 or in the next cycle scheduled for April2018. Reflecting another improvement from
NQF's 2017 Consensus. Development Process redesign, scientific review of complex measures in these
topic areas will be conducted by the Scientific Methods Panel, and NQF staff will review will review
noncomplex measures. This input will be shared with the standing committees in their consideration of
measures for endorsement. Furthermore, all standing committees will apply the NQF measure
prioritization criteria in their new work.
All-Cause Admissions and Readmissions
Despite the healthcare industry's focus in recent years on reducing preventable readmissions,
challenges persist, especially for patients who suffer from chronic and co morbid conditions. Measuring
critical factors that affect the quality of patient care can provide valuable information to help providers
better address patients' health needs after hospitalization and keep them from unnecessarily returning
to the hospital.
Reducing avoidable readmissions is a national priority. NQF will review measures related to admissions
and readmissions, both all--cause and those specific to certain conditions, such as heart failure. No
measures were submitted for this project for the September 2017 cycle. Measures are expected for the
April 2018 cycle.
Behavioral Health and Substance Use
Behavioral health encompasses a range of treatments and services for individuals who are at risk or
suffering from mental, behavioral, and/or addictive disorders. These may include substance abuse, post·
traumatic stress disorder, and anxiety, or depression. Behavioral health disorders are a leading cause of
disability, and treatment continues to be a source of rising healthcare costs in the United States. 87
NQF will review measures that can help achieve better behavioral health and healthcare, with a focus on
attention deficit/hyperactivity disorder {ADHD), depression, and substance abuse screening, primary
care, and treatment. Better measures of the quality of behavioral healthcare services can help ensure
that people receive timely, coordinated, and effective care that ultimately leads to better outcomes and
improved overall health. Five measures were submitted for this project for the September 2017 cycle.
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Cancer
Cancer takes the lives of more than 1,600 Americans each day. 88 More and more people are also
surviving cancer: nearly 14.5 million Americans with a history of cancer were alive in 2014, and it is
estimated that the number of cancer survivors in the United States will increase to almost 19 million by
2024. 89 In addition, according to the Agency for Healthcare and Research Quality (AHRQ), the cost of
cancer care in the United States has more than doubled in the 10 years from 2001 to 2011. Quality
measures are needed to ensure effectiveness, value, and efficiency of cancer care for patients and their
families.
NQF will review measures to assess the quality of care for breast, colon, prostate, esophageal, lung, and
other cancers. Since cancer care is complex and provided in multiple settings by multiple providers,
high-quality measures that capture the complexity of this care as well care coordination are essential.
NQF seeks to endorse measures focused on cancer screening and treatment. Five measures wert'
submitted for this project for the September 2017 cycle.
Cardiovascular
More than 800,000 Americans die every year from heart disease and many people living with heart
disease are seriously ill and disabled. 90 Heart disease is also a tremendous financial burden, accounting
for approximately $300 billion in annual U.S. healthcare expenditures. 91 By improving measurement of
heart disease treatment, interventions, and outcomes, NQF aims to improve the quality of care and
health outcomes for the millions of Americans affected by heart disease.
NQF will review measures for heart conditions such as hypertension, coronary artery disease, acute
myocardial infarction, percutaneous coronary intervention, heart failure, and atrial fibrillation.
Measures may assess outcomes, treatments, diagnostic studies, interventions,
or procedures associated
with these conditions. Six measures were submitted for this project for the September 2017 cycle.
Cost and Efficiency
Healthcare spending in the United States is unmatched by any country in the world, without
a
corresponding increase in better outcomes or overall vaiue. 92 According to CMS, national healthcare
expenditures rose 5.8 percent to $3.2 trillion in 2015, or$9,990 per person. 93 Additionally, estimates
suggest that as much as 30 percent of all healthcare spending is wasted on unnecessary or ineffective
services, 94 lmproving efficiency within the healthcare system holds the potential both to reduce the rate
of cost growth and improve the quality of care provided.
To help understand how and where healthcare dollars are spent, NQF will review measures focused on
the cost of care, payment, and efficiency for all conditions. Measures may, for example, evaluate total
care costs for individual patients, as well as look at specific treatment costs for any condition. No
measures were submitted for this project for the September 2017 cycle. Measures are expected for the
April 2018 cycle.
Geriatrics and Palliative Care
Improving both access to, and the quality of, geriatric and palliative care in all healthcare settings is
becoming increasingly important About 48 million Americans are age 65 and older, and that number is
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projected to grow to over 88 million by 2050.95 Increasingly, older Americans are living with multiple
chronic conditions that can lead to gradual and prolonged functional decline. Palliative care has been
shown to improve quality of life, enhance information and communication, lower costs of care, and
even help some patients live longer. However, the quality and accessibility of palliative care are highly
variable in hospital and outpatient settings, and many patients who receive end-of-Hfe palliative care
through hospice enroll too late to benefit fully from this care. Consensus on endorsed measures that
capture the important structures, processes, and outcomes of palliative and geriatric care will help to
improve these services across care settings.
NQF will reconvene its Palliative and End-of-life Care Standing Committee as the Geriatrics and
Palliative Care Committee to review measures focused on experience with care, care planning,
management of pain or difficulty breathing, care preferences, and quality of care at the end of life. No
measures were submitted for this project for the September 2017 cycle. Measures are expected for the
April 2018 cycle.
Neurology
Neurological conditions can be severe, affecting the normal function of both the spinal cord and the
brain by impeding muscle function, lung function, swallowing, and even breathing. With more than 600
neurologic diseases, neurological conditions are a leading cause of death in the United States and a
major contributor to health care costs. According to the U.S. Centers for Disease Control and Prevention,
1 in 26 people will develop epilepsy during their life. In addition, nearly 800,000 Americans suffer a
stroke each year, making stroke the fifth leading cause of death in the nation. 96 The Alzheimer's
Association estimates that more than 5 million Americans are living with Alzheimer's disease. The
estimated cost of care for people with dementia was $230 billion in 2016. 97
To help guide improved treatment and care for millions of Americans with neurological disorders, NQF
will review measures in key areas, including stroke, epilepsy, multiple sclerosis, dementia and
Alzheimer's disease, Parkinson's disease, and traumatic brain injury. No measures were submitted for
this project for the September 2017 cycle. Measures are expected for the April 2018 cycle.
Patient Experience and Function
High-quality performance measures are essential to provide information and insight on how providers
are responding to the needs and preferences of patients and families. Measures that address how
healthcare organizations can create effective care practices that support positive patient experiences
and improved function are vital to improving the quality of care.
NQF's patient experience and function work encompasses quality measures previously designated to
NQF's Person- and Family-Centered Care and Care Coordination Standing Committees. In this
consolidated area of work, NQF will review measures that assess health-related quality of life, patient
and family engagement in care, functional status, symptoms and symptom burden, experience with
care, and care coordination. Eight measures were submitted for this project for the September 2017
cycle.
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Patient Safety
Despite significant achievements in measuring and addressing patient harms, tens of thousands of
preventable injuries to patients still occur each year, and many of these harms have dire consequences.
For example, an estimated 5 to 10 percent of hospitalized patients acquire healthcare-associated
infections each year, resulting in 99,000 deaths and $20 billion annually in health care costs. 98
In this new work, NQF will review measures focused on pressure ulcers, healthcare-acquired conditions,
sepsis, medication management, and mortality rates. One measure was submitted for this project for
the September 2017 cycle.
Perinatal and Women's Health
The United States spends more on perinatal healthcare than any other health sector ($111 billion in
2010), 99 but ranks last in maternal outcomes among all industrialized nations. 100 With nearly 4 million
u.s. births in 2015/01 and great disparities in care and outcomes among different racial and ethnic
groups, reproductive and perinatal healthcare is a major concern for women, mothers, babies, and the
providers who care for them, and accordingly, is important for quality measurement. 102
NQF will reconvene the multistakeholder Perinatal and Reproductive Health Standing Committee as the
Perinatal and Women's Health Standing Committee to review measures focused on reproductive health,
pregnancy, prenatal care, labor and delivery, post-partum care for newborns, and childbirth-related
issues for women. One measure was submitted for this project for the September 2017 cycle.
Prevention and Population Health
The United States ranks lower than many other developed nations on health outcomes, yet spends
more on healthcare than any other nation, 1na and continues to struggle with significant disparities in
health and healthcare. In addition, social risk factors contribute to up to 60 percent of deaths in the
United States. However, most U.S. healthcare dollars are spent on treatment rather than social and
other services that can help prevent disease. 104 1mproving population health requires a commitment to
sustained prevention efforts, including adopting healthy behaviors, increased screening for disease,
reducing harmful environmental exposures, and mitigating the effects of social risk factors (e.g.,
economic, geographic, and race/ethnicity) on health.
Performance measures can help to monitor the success of population health improvement initiatives
and help focus future health improvement efforts on proven, effective strategies. NQF will reconvene
the Health and Well-Being Standing Committee as the Prevention and Population Health Standing
Committee to review measures focused on smoking, diet, disease incidence and prevalence, prevention
and screening, practices to promote healthy living, community interventions, and modifiable social,
economic, and environmental determinants of health with a demonstrable relationship to prevention
and population health. Eight measures were submitted for this project for the September 2017 cycle.
Primary Care and Chronic Illness
Primary care has a central role in improving the health of people and populations. Primary care
practitioners manage the uniqueness and complexities of each patient. In this setting, the diagnosis and
treatment of the patient focus on the health of the entire patient and not a single disease. Chronic
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illnesses are long-lasting or persistent health conditions or diseases that patients and providers must
manage on an ongoing basis. The incidence, impact, and cost of chronic disease is increasing in the
United States. It is essential to better understand the scope of two ofthe most common and most
expensive chronic diseases confronting the nation: diabetes, which affects at least 29 million
Americans, 105 and asthma, which affects 25 million Americans. 106
High-quality performance measurement that captures the complexity of primary care and chronic
illnesses is essential to improve diagnosis, treatment, and management of conditions. NO.F will review
measures in these important healthcare areas under a consolidated measure portfolio that reflects the
importance of caring for chronic illness in primary care settings. Measures may focus on nonsurgical eye
or ear, nose, and throat conditions, diabetes care, osteoporosis, HIV, rheumatoid arthritis, gout, back
pain, asthma, chronic obstructive pulmonary disease (COPD), and acute bronchitis. No measures were
submitted for this project for the September 2017 cycle. Measures are expected for the April2018 cycle.
Renal
Renal disease is widespread in the United States. An estimated 30 million American adults (15 percent of
the population) have chronic kidney disease (CKD), which is associated with premature mortality,
decreased quality of life, and increased healthcare costs. Left untreated, CKD can result in ESRD, which
afflicts over half a million people in the United States. 107 Measures can help ensure that people with
renal disease receive high-quality care.
NQF wHI review measures that address conditions, treatments, interventions, or procedures relating to
ESRD, CKD, and other renal conditions, for accountability and quality improvement. No measures were
submitted for this project for the September 2017 cycle. Measures are expected for the April 2018 cycle.
Surgery
In 2010, 51.4 million inpatient procedures and 53.3 million surgical and nonsurgical procedures were
performed in ambulatory surgery centers. 108 Ambulatory surgery centers are the fastest growing
provider type participating in Medicare. 109 ln 2012, 28 percent of hospital stays (excluding maternal and
neonatal stays) involved operating room procedures and accounted for nearly half of total hospital
°
costs. 11 Consumers are increasingly turning to public reports of quality measures to make decisions
about surgical care, looking specifically at the likelihood of surgical success, i.e., the surgery achieving its
intended outcome and avoiding complications. Despite advances in improving surgical care and given
the increasing rates of surgical procedures and associated costs, gaps persist in performance
measurement and reporting that impair efforts to improve the safety and quality of surgical care.
While significant strides have been made to make surgery safer and improve outcomes, patientcentered measures that assess shared accountability and overall surgical quality are still needed. In this
new work, NQF will review measures that assess pre- and post-surgical care, timing of prophylactic
antibiotics, and adverse surgical outcomes. Seven measures were submitted for this project for the
September 2017 cycle.
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IV.
Stakeholder Recommendations on Quality and Efficiency Measures
Section 1890(b)(5)(A)(vi} of the Social Security Act requires the CBE to include in this report a description
of matters related to multistakeholder group input on the selection of quality and efficiency measures
from among: (I) measures that have been endorsed by the entity; and {II) 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.
Measure Applications Partnership
Under section 1890A of the Act, HHS is required to establish a pre-ru/emaking 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. 111
First convened in 2011, NQF's MAP recommends performance measures for use in federal healthcare
quality programs. The MAP pre-rulemaking process enables a unique multistakeholder dialogue about
priorities for measurement in these programs. It provides private- and public-sector stakeholders across
the care continuum-including patients, clinicians, providers, purchasers, and payers-with the
opportunity to identify and recommend the highest-value measures for each program as well as to
provide strategic guidance across programs. Throughout its six years of annual review, MAP has worked
toward the goal of lowering costs while improving quality, making measurement meaningful for
improvement while reducing unnecessary administrative burden, and ensuring that patients and
consumers get the information they need to support their healthcare decision making.
MAP convenes the Rural Health Workgroup and three setting-specific workgroups (Hospital, Clinician,
and Post-Acute/Long-Term Care), as well as the Coordinating Committee, an overarching body that
provides strategic direction and synchronization among the workgroups. More than 150 healthcare
leaders from 90 organizations who regularly use measures and measurement information serve on MAP
and participate in its discussions. The annual list of measures under consideration (MUC) for use in
federal programs and MAP's deliberations on these measures are transparent and open for public
comment. Each MAP workgroup considers public comment in its review of measures. For detailed
information regarding MAP representatives, criteria for selection to MAP, and rosters, please see
Appendix E and Appendix G.
MAP's efforts help to facilitate the alignment or use of the same measures across multiple federal
programs. Alignment of measures helps providers better identify key areas in which to improve quality;
reduces burdensome data collection that could distract hospitals, physicians, and nurses from their care
delivery work; and helps to curb the proliferation of redundant measures, which could confuse patients
and payers. 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; and payer
types. Although MAP provides recommendations to HHS, many are also adopted by the private sector.
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New in 2017, MAP's Rural Health Workgroup will provide guidance on measures specific to the needs
and challenges of rural providers and residents.
2011 Pre-Rulemaking Input
MAP completed its deliberations for the 2016·2017 pre-rulemaking cycle with the publication of its
annual reports in February and March 2017, marking MAP's sixth review of measures for HHS programs.
MAP reviewed 71 unique performance measures under consideration for use in 16 federal quality
reporting and value-based payment programs (see .8Jm.§'ndix F) covering clinician, hospital, and postacute/long-term care settings.
The MAP Measure Selection Criteria guides the review process for the measures under consideration
(see
Over the course of the review process, MAP promotes alignment of measures across
HHS programs and with private-sector efforts. MAP also incorporates measure use and performance
information into its decision making to provide HHS with specific recommendations about the best use
of available measures as well as filling measure gaps.
Guidance on Measures Currently in Use
Currently, there are a total of 634 measures used in programs that MAP reviews. In its 2017 guidance,
MAP conducted a holistic review of the current measure sets used in federal programs and
recommended significant improvements to reduce measure burden.
Other Process Improvements
In addition to providing guidance on measures currently in use in federal programs, MAP also made
process improvements to address the challenge of reviewing measures early in their lifecycle. MAP is
committed to the scientific integrity of the measures used in accountability programs but historically has
had limited information about the reliability and validity of the measures under consideration. Some of
the measures under consideration in a given year may not yet have been reviewed for NQF
endorsement, and some measures under consideration may still be in development or testing.
MAP now reviews all measures using the same decision categories, with the addition of a new category
in 2016-2017, Refine and Resubmit Prior to Rulemaking. The other categories include Support for
Rulemaking, Conditional Support for Rulemaking, and Do Not Support for Rulemaking. MAP added the
Refine and Resubmit category after it determined that all measures under consideration should be
reviewed using the same process and that measures still in development would not be reviewed
separately. MAP created this decision category to preserve Its ability to support the concept of a
measure under consideration and encourage its continued development, while noting that significant
changes may be needed prior to its implementation. The Refine and Resubmit category differs from the
Conditional Support for Rule making category by signaling that a larger change is needed to the measure
under consideration or that the measure under consideration has not completed development and
testing. A measure may receive this designation if MAP determines it is not an efficient use of
measurement resources, it may not be feasible to report, it may not be reliable and valid for the setting
and level of analysis for which it is being considered, or if implementation issues have been identified.
The intent of this category was that measures receiving this designation would be brought back to MAP
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prior to implementation. However, the HHS Secretary has statutory authority to propose measures after
considering MAP's recommendations.
In 2017, MAP also completed improvements to integrate the MAP and NQF measure endorsement
processes to provide MAP members and the public better information about the endorsement status of
measures under consideration. For example, if a measure under consideration has undergone measure
endorsement review, MAP members received the results of that review in the preliminary analysis and
the discussion guide about the measure. MAP recommendations are also provided to the relevant NQF
standing committee if and when a measure under consideration for use in federal programs is reviewed
for endorsement.
MAP members have expressed a desire to understand more about what happens to a measure under
consideration after MAP's review, particularly when MAP recommends potential improvements to the
measure or the measure has not yet completed testing. Through the addition of the Refine and
Resubmit Prior to Rulemaking category, MAP has established a pathway to receive feedback from CMS
and measure developers on how its recommendations have been addressed.
NQF piloted a feedback loop process in the 2016-2017 pre-rulemaking cycle for CMS to provide the
PAC/LTC Workgroup with updates on the development and endorsement of selected measures included
on previous lists of measures under consideration. This review was not intended to allow for a change in
MAP's recommendations about a measurei rather, it provided an opportunity for MAP members to
better understand whether or how their suggested refinements and conditions of support have been
met. The feedback loop process was well received by the PAC/LTC Workgroup. MAP members
appreciated the opportunity to better understand how CMS implemented their input on measures
under consideration. CMS also noted the value of the feedback loop to build relationships and better
inform stakeholders. NQF plans to implement the feedback loop process across MAP for the 2017-2018
pre-rule making cycle.
MAP Clinician Workgroup
In its 2016-2017 cycle, MAP reviewed clinician-level measures under consideration for the following
programs:
•
Merit-Based Incentive Payment System (MIPS). MIPS is one of two tracks in the Quality Payment
Program (QPP).
•
Medicare Shared Savings Program. The Shared Savings Program is designed to create incentives
for healthcare providers to work together voluntarily to coordinate care and improve quality for
their patient population.
MIPS was established by section 101(c)of MACRA. 112 MIPS consolidates aspects of three existing
Medicare quality reporting and value-based purchasing programs for clinicians. MIPS applies positive
and negative payment adjustments for MIPS eligible clinicians (ECs) based on performance in four
categories:
•
Quality: replaces the Physician Quality Reporting System (PQRS) program and Value-Based
Payment Modifier (VM) programs
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•
Cost: rep faces the VM program
•
Advancing Care Information: replaces the Electronic Health Records Incentive Program for
eligible professionals
•
Improvement Activities: new performance category
MAP reviewed 18 measures for the MIPS. MAP supported two measures and conditionally supported
seven measures, including three patient-reported outcome-based performance measures pending the
completion of measure testing that supports variation in performance at the individual clinician level
and the receipt of NQF endorsement. MAP recommended that eight measures under consideration be
refined and resubmitted prior to rulemaking. The Committee noted that the measures addressed
promising concepts for measurement (e.g., in population health and appropriate use) but stressed the
need for further testing to be completed prior to implementation in the MIPS. MAP suggested
refinements to one measure of smoking prevalence that was under consideration for both the MIPS and
the Shared Savings Program, raising concerns about performance goals and attribution, as a clinician
would be held accountable for the county·level smoking rate.
MAP recognized that MIPS includes a large number of measures across a wide range of specialties and
the majority of measures may not be applicable to all or most specialties. Therefore, a larger number of
measures is needed to ensure all eligible clinicians can participate. MAP also noted that the design of
the program, where clinicians choose which measures to report, can influence whether or not there is
still an opportunity to improve performance on a measure, as some measures are reported by a smaller
number of clinicians. These factors make it challenging to streamline the MIPS measure set.
Measures for MIPS on the 2016 MUC list were under consideration for potential implementation in 2018
affecting the payment year 2020 measure set and future years.
The Medicare Shared Savings Program was established by Section 3022 of the Affordable Care Act
(ACA). 113 Eligible providers and suppliers may participate in the Shared Savings Program by creating or
participating in an Accountable Care Organization (ACO). ACOs that meet the program requirements and
quality performance standards are eligible to share in savings. There are three participation options: (1)
one-sided risk model (sharing of savings only for all three years, (2) two-sided risk model (sharing of
savings and losses for all three years) with preliminary prospective assignment with retrospective
reconciliation, and (3) two-sided risk model (sharing of savings and losses for all three years) with
prospective assignment.
MAP also considered the local smoking prevalence measure that was under consideration for MIPS for
the Shared Savings Program. MAP agreed with the importance of reducing smoking rates but
recommended the measure be refined and resubmitted, noting concerns about fairly comparing ACOs
as smoking rates can vary significantly in different areas of the country. MAP recommended ensuring
that the measure is properly risk adjusted and suggested measuring the change in rates rather than
comparing rates across the country, noting concerns about risk adjustment and variation in smoking
prevalence in different geographic regions.
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An overarching theme of MAP's pre-rulemaking recommendations for measures in the MIPS and the
Shared Savings Program is that high-value measures are needed in both programs. MAP emphasized
moving beyond the process measures that make up the majority of the current measures. MAP has
identified the following measure types as high-value:
•
•
•
•
•
•
Outcome measures (e.g., mortality, adverse events, functional status, patient safety,
complications, or intermediate outcomes)
Patient-reported outcomes where the patients provide the data about the results of their
treatment, level of function, and health status
Measures addressing patient experience, care coordination, population health, quality of
life, or impact on equity
Appropriateness, overuse, efficiency, and cost-of-care measures
Composite measures
Process measures with a strong evidence-based link to patient outcomes
However, MAP members recognized the associated complexities of developing, testing, and properly
attributing outcome measures at the clinician level. MAP members requested that CMS and specialty
societies work together to create a suite of high-impact measures that are actionable by the individual
clinician and demonstrate the ability to improve quality.
MAP Hospital Workgroup
The MAP Hospital Workgroup reviewed measures under consideration for seven hospital and setting·
specific programs, making the following recommendations.
End-Stage Renal Disease Quality Incentive Program. The End-Stage Renal Disease Quality Incentive
Program (ESRD QIP) is a value-based purchasing program that links a portion of an end·stage renal
facility's payment under the ESRD PPS to its performance on quality measures. This program was
established to promote the provision of high-quality renal dialysis services by dialysis facilities.
MAP reviewed three measures under consideration for the ERSD QIP program, supporting two and
recommending that one be refined and resubmitted prior to rulemaking.
PPS·Exempt Cancer Hospital Quality Reporting Program. The Prospective Payment System (PPS)Exempt Cancer Hospital Quality Reporting (PCHQR) program is a quality reporting program for PPSexempt cancer hospitals. 114 The program's goal is to provide information to the public about the quality
of care that is furnished
in the 11 cancer hospitals that are exempt from payment under the Medicare
Inpatient Prospective Payment System (IPPS).
MAP reviewed five measures under consideration for the PCHQR program, recommending four and not
supporting one.
Ambulatory Surgery Center Quality Reporting Program. The Ambulatory Surgical Center Quality
Reporting {ASCQR) program is a pay-for-reporting program. 115 Ambulatory Surgical Centers (ASCs) that
fail to meet program requirements receive a 2 percent reduction to their annual payment increase. The
ASC program was established to provide information about the quality of care provided at ASCs.
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MAP reviewed three measures under consideration for the ASCQR program, conditionally supporting
three and recommending that two be refined and resubmitted prior to rule making.
Inpatient Psychiatric Facility Quality Reporting Program. The Inpatient Psychiatric Facility Quality
Reporting {IPFQR} Program 116 is a pay-for-reporting program that requires inpatient psychiatric facilities
(IPFs} to meet program requirements, including submitting data on measures, to avoid receiving a 2
percent reduction in their annual update to a standard federal rate for discharges for the IPF occurring
during a particular year. The IPFQR program provides information about the quality of care in inpatient
psychiatric facilities.
MAP reviewed three measures under consideration for the IPFQR program, recommending that all three
be refined and resubmitted prior to rulemaking.
Hospital Outpatient Quality Reporting Program. The Hospital Outpatient Quality Reporting (OQR}
Program (OQR) is a pay-for-reporting program. 117 Subsection (d) hospitals that fail to meet program
requirements receive a 2.0 percentage point reduction to their OPD fee schedule increase factor. This
program established a system for collecting and providing quality data about hospital outpatient
services.
MAP reviewed three measures under consideration for the Hospital OQR Program, supporting one,
conditionally supporting another, and recommending that one be refined and resubmitted prior to
rulemaking.
Hospital Readmissions Reduction Program. The Hospital Readmissions Reduction Program (HRRP) is
similar to the hospital value-based purchasing program 118; it aims to reduce readmissions to Medicare
subsection (d) hospitals, defined as a general, acute case, short-term hospitals. Psychiatric hospitals,
rehabilitation hospitals, long-term care hospitals, children's hospitals, cancer hospitals, and critical
access hospitals are exempt from the program. Diagnosis-related group (DRG) payment rates are
reduced based on a hospital's ratio of actual to expected readmissions.
There were no measures under consideration for the HRRP in the 2016-2017 pre-rule making
deliberations. However, MAP reviewed the current set of six measures and raised concerns that safetynet hospitals may be disproportionately penalized by the HRRP, as the measures are not currently risk
adjusted for social risk factors. MAP recommended that CMS consider the recommendations of the
Assistant Secretary for Planning and Evaluation (ASPE} in the Report to Congress: Social Risk Factors and
Performance Under Medicare's Value-Based Purchasing Programs 119 to mitigate the impact of the HRRP
on safety net hospitals.
Hospital Inpatient Quality Reporting Program/Medicare and Medicaid EHR Incentive Program for
Eligible Hospitals and Critical Access Hospitals (Meaningful Use). The Hospital Inpatient Quality
Reporting (IQR) Program is a pay-for-reporting program that addresses the quality of care furnished by
hospitals and requires subsection (d) hospitals to meet program requirements or be subject to a onequarter reduction to their applicable percentage increase.
MAP reviewed 15 measures under consideration for the HospitaiiQR Program and/or EHR Incentive
Programs, conditionally supporting one, suggesting refinements to nine, and not supporting five.
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When reviewing the current measure set for HospitaiiQR Program, MAP highlighted the need for
alignment across hospital programs. In particular, MAP members noted the 21st Century Cures Act
provisions that require consideration of the proportion of dually eligible patients served by facilities
participating in the HRRP. MAP recommended that CMS explore ways to align the readmissions
measures used both for the Hospital IQR Program and HRRP to ensure consistency in the information
provided to both hospitals and consumers. In addition, MAP suggested that CMS consider ASPE's
recommendations in its report on social risk factors in value-based purchasing programs, as some
measures used in the IQR program also are used in the Hospital Value-Based Purchasing Program (VBP)
and the HRRP.
Hospital Value-Based Purchasing Program. The Hospital VBP program Is a value-based purchasing
program 120 designed to improve the quality of hospital inpatient services by linking a portion of a
hospital's Medicare payment under the IPPS to its performance on quality measures. Hospitals are
eligible to receive incentive payments based either on how well they perform compared with other
hospitals or how much their performance has improved over time.
MAP reviewed one measure under consideration for the Hospital VBP Program and did not support it.
MAP also reviewed the 21 current measures in the program and suggested opportunities for
improvement. First, MAP recommended that CMS review ASPE's recommendations and consider ways
to mitigate the effect of the Hospital VBP Program on safety-net hospitals, as social risk may influence
the efficiency and mortality measures currently included in the program. Secondly, MAP raised concerns
about the reliability, actionability, and usability of the PSI-90 measure used in the program and urged
CMS to develop new patient safety measures, such as measures addressing all-cause harm. Finally, MAP
noted concerns about the potential overlap among the efficiency measures used in the program. For
example, MAP noted that the Medicare Spending per Beneficiary Measure would include episodes
captured in the risk-standardized payment associated with the 30 day-episode of care measures for
acute myocardial infarction and heart failure and that including both measures would lead to a hospital
being rewarded or penalized twice forthe same patient case.
Hospital-Acquired Condition Reduction Program. The Hospital-Acquired Condition Reduction Program
(HACRP) is a value-based purchasing program; it penalizes hospitals for occurrences of hospital·acquired
conditions (HACs). 121 Hospitals with the highest rates of HACs will have their Medicare payments
reduced by 1 percent. Hospitals are currently scored on measures in two domains: PSI-90 and National
Healthcare Safety Network measures. The domain scores are used to calculate the Total HAC Score.
Hospitals above the 75th percentile for their Total HAC Score are subject to the payment reduction.
There were no measures under consideration for the HACRP in the 2016·2017 pre-rulemaking
deliberations. However, MAP reviewed the measures currently used in the program and recommended
that HHS develop new safety measures to replace PSI-90 in the HACRP as MAP had concerns about the
actionability and reliability of this measure.
The MAP Hospital Workgroup identified the need for high-value measures across programs. Such
measures would address key areas where measure development is needed, including measures to
evaluate the appropriate use of health interventions and testing; measures of care transitions, which are
pivotal to improving healthcare quality, especially after hospitalization; and measures of patient-
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reported outcomes. MAP also emphasized the need for measures that will drive improvement and
foster more consistent performance among providers. MAP looked to the potential use of eMeasures to
reduce collection and administrative burden on providers, noting that decisions to select a measure
should weigh the burden to report on the measure against its potential to improve care quality.
MAP PAC/LTC Workgroup
The Measure Applications Partnership (MAP) reviewed measures under consideration for five settingspecific federal programs addressing post-acute care (PAC) and long-term care (LTC). MAP provided
feedback on the current measure sets for these programs and identified several overarching themes,
including: (1) implementation of the Improving Medicare Post-Acute Care Transformation (IMPACT} Act
and (2} continued opportunities to address quality. MAP also discussed the current measure set of a
sixth program for which no new measures were submitted.
Inpatient Rehabilitation Facility Quality Reporting Program. The Inpatient Rehabilitation Facility Quality
Reporting Program (IRF QRP) is a pay-for-reporting program that addresses the quality of care furnished
by IRFs to Medicare beneficiaries. 122 This program applies to IRFs that are paid by Medicare under the
IRF prospective payment system (PPS), including freestanding IRFs and inpatient rehabilitation units of
hospitals or critical care access hospitals {CAHs).
MAP reviewed three measures under consideration for the IRF QRP, conditionally supporting or\e and
recommending two others to be refined and resubmitted prior to rulemaking. MAP also reviewed the
measures currently in the program and noted the need for measures that address issues such as patient
and family engagement, and nutrition.
Long-Term Care Hospital Quality Reporting Program. The Long-Term Care Hospital Quality Reporting
Program (LTCH QRP) is a pay-for-reporting programm that addresses the quality of care furnished by
LTCHs to Medicare beneficiaries. This program applies to all hospitals certified by Medicare as LTCHs.
MAP reviewed three measures under consideration for the LTCH QRP, conditionally supporting one and
recommending that two others be refined and resubmitted prior to rulemaking. MAP also reviewed the
measures currently used in the program, noting that LTCH measurement could be improved, for
example, by replacing measures of specific infections with a measure of all facility-acquired infections.
MAP also identified gaps in the measure set, including the need for measures addressing the transfer of
information between attending clinicians, and not just between settings. MAP also recommended
adding an LTCH-specific Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to
assess patient experience with care.
Skilled Nursing Facility Quality Reporting Program. The Skilled Nursing Facility Quality Reporting
Program (SNF QRP) is a pay-for-reporting programn4 that addresses the quality of care furnished by
SNFs to Medicare beneficiaries. This program applies to freestanding SNFs, SNFs affiliated with acute
care facilities, and all non-SNF swing-bed rural hospitals. Beginning with fiscal year 2018, SNFs that do
not submit data as required under the SNF QRP for a fiscal year will receive a 2 percentage reduction to
their annual market basket percentage that would otherwise apply for that fiscal year.
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MAP reviewed three measures under consideration for the SNF QRP, conditionally supporting one and
recommending that the two others be refined and resubmitted prior to rulemaking. MAP reviewed the
measures currently in the program and suggested that the measure set could be improved by taking a
person-centered focus to measurement that addresses advance directives and additional aspects of care
coordination, such as the efficacy of transfers from acute care hospitals to skilled nursing facilities, the
transfer of information between facilities and attending clinicians, and the patient's experience.
Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP). The Skilled Nursing Facility ValueBased Purchasing Program (SNF VBP) is a value-based purchasing program 125 that links Medicare
payments to SNFs under the SNF PPS to their performance on a measure of all-cause all-condition
hospital readmission rates.
MAP identified opportunities to clarify measure specifications for the program to ensure alignment with
program goals.
Home Health Quality Reporting Program. The Home Health Quality Reporting Program (HH QRP}m is a
pay-for-reporting program established in accordance with section 1895(b)(3)(B)(v)(ll) of the Social
Security Act, and it aims to improve the quality of care provided to home health patients. Home health
agencies (HHAsl that do not comply with the program's incentive structure are subject to a 2 percent
reduction in their annual home health market basket percentage increase applicable to the HHA for such
year. These data are made publicly available through the Home Health Compare website to provide
national ratings on the quality of HHAs.
MAP reviewed five measures under consideration for the HH QRP, conditionally supporting three and
recommending that the two others be refined and resubmitted prior to rulemaking. In reviewing the
measures currently in the program, MAP affirmed the need for a streamlined measure set to reduce the
burden on providers while ensuring that consumers and other stakeholders have the information they
need to support their decision making.
Hospice Quality Reporting Program. The Hospice Quality Reporting Program (HQRP) is a pay-forreporting program 127 established by Section 3004 of the Affordable Care Act. The HQRP applies to all
hospices, regardless of setting. Faflure to submit quality data will result in a 2 percent reduction to a
hospice's annual payment update.
MAP reviewed eight measures under consideration for the HQRP and supported all of them. MAP
reviewed the measures currently in the program, noting several measurement gaps to be addressed in
future rulemaking cycles. These gaps include measures of medication management at the end of life, the
provision of bereavement services, patient care preferences, and measures that address symptom
management for other conditions besides cancer, particularly dementia. MAP also noted the need to
include outcome measures in the Hospice QRP set. Finally, MAP emphasized the importance of publicly
reporting measure results to help guide patient decision making.
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V.
35367
Gaps on Endorsed Quality and Efficiency Measures Across HHS Programs
Under section 1890(b}(S)(A)(iv) of the Act, the entity is required to describe in the annual report 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.
NQF is committed to measurement that drives meaningful improvement in the healthcare system. ln
addition to endorsing high-value measures and recommending measures for use in federal programs,
NQF standing committees, its Measure Applications Partnership, and Medicaid workgroups also identify
measure gaps-areas in healthcare where high-value measures are too few or nonexistent-to drive
improvement.
During their 2017 deliberations, NQF standing committees that reviewed measures for endorsement or
conducted other activities related to improving NQF's measure portfolios discussed and identified more
than 100 measurement gaps. NQF's self-funded initial measure prioritization efforts surfaced important
measurement gaps in palliative and end-of-life care. Standing committees also identified a large number
of measure gaps in behavioral health, pediatric, and patient safety topical areas. These gaps are included
in Appendix H.
The Measure Applications Partnership provided feedback on measure gaps across and within federal
programs, guided by CMS input in the Program Specific Measure Priorities and Needs document on
high-priority domains. 128 Medicare measure gaps identified by MAP are included in Appendix I. In
addition, NQF's Medicaid Task Forces and Dual Eligible Beneficiaries Workgroup also identified gaps in
the Adult and Child Core Sets and the Dual Eligible Beneficiaries Family of Measures. These gaps are
included in Appendix J.
VI.
Gaps in Evidence and Targeted Research Needs
Under section 1890(b}(5)(A)(v) of the Act, the entity Is 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.
Several NQF projects completed in 2017, as well as one that is underway, create needed strategic
approaches, or frameworks, to measure quality in areas critical to improving health and healthcare for
the nation but for which quality measures are too few, are under developed, or non-existent.
A measurement framework is a conceptual model for organizing ideas that are important to measure for
a topic area and for describing how measurement should take place (i.e., whose performance should be
measured, care settings where measurement is needed, when measurement should occur, or which
individuals should be included in measurement). Frameworks provide a structure for organizing
currently available measures, areas where gaps exist, and prioritization for future measure
development.
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NQF's foundational frameworks identify and address measurement gaps in important healthcare areas,
underpin future efforts to improve quality through metrics, and ensure safer, patient-centered, costeffective care that reflects current science and evidence.
NQF completed projects to create strategic measurement frameworks for assessing the quality of
telehealth, diagnostic quality and accuracy, and transitions of care into and out of emergency
departments. NQF also developed a measurement structure for assessing progress toward
interoperability, an important area for advancing care that continues to present significant challenges to
healthcare organizations. In other work, NQF continued its efforts to support structured reporting of
patient safety events in hospitals and other care settings. NQF also began a new project to identify
measure concepts that can improve the quality and safety of care in ambulatory care settings.
Telehealth
Telehealth offers the potential to transform the healthcare delivery system by providing technological
methods of care delivery that overcome geographical distance, enhance access to care, and create
greater efficiencies in the delivery of care. Services provided through telehealth are expected to increase
due to new reimbursement strategies for Medicare providers who offer these services as part of
MACRA.
The Health Resources and Services Administration (HRSA) defines telehealth as "the use of electronic
information and telecommunications technologies to support and promote clinical healthcare, patient
and professional health-related education, public health, and health administration.'' 129 Although it does
not represent all existing definitions for this important area of health IT across both the private and
public sectors, 130 there is general consensus that telehealth supports a range of clinical activities,
including:
•
Enhancing interactions among providers to improve patient care (for example, consultation with
distant specialists by the direct care provider);
•
Supporting provider-to-provider training;
•
Enhancing service capacity and quality (for example, small rural hospital emergency
departments and pharmacy services);
•
Enabling direct patient-provider interaction (such as follow-up for diabetes or hypertension, or
urgent care
•
Managing patients with multiple chronic conditions from a distance; and
•
Monitoring patient health and activities (for example, home monitoring equipment linked to a
distant provider). 131
These activities are especially useful in communities where access to appropriate healthcare services is
limited. Compared to residents of urban communities, residents of rural and frontier communities are
more likely to be older and to have more risk factors associated with their health conditions. The supply
of healthcare professionals to treat certain conditions, such as mental and behavioral health disorders
and chronic disease, can be scarce in many of these areas, and existing providers may have limited
training in specialized areas of care. To address these challenges, some rural hospitals and other
healthcare settings have adopted telehealth, including video communication between providers and the
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sharing of information, such as radiological and imaging reports. 132 Similar strategies have been adopted
in urban and suburban settings, especially for specialties with significant workforce shortages and/or
maldistribution (e.g., dermatology and psychiatry), or where long delays to schedule new patient
appointments may occur.
In a one-year project that concluded in August 2017, NQF's Telehealth Committee was charged with
developing a measurement framework that identifies critical areas where measurement can effectively
assess the quality and impact of telehealth services and serves as a conceptual foundation for new
measures, where needed. The Committee recommended measuring the quality of telehealth in four
broad categories: patients' access to care, financial impact to patients and their care team, patient and
clinician experience, and effectiveness of clinical and operational systems. Within these categories, NQF
identified six key areas as having the highest priority for measurement in telehealth, including travel,
timeliness of care, actionable information, added value of telehealth to provide evidence-based
practices, patient empowerment, and care coordination.
The Committee identified 16 NQF-endorsed measures that can be used initially to measure telehealth
quality. These measures span a variety of conditions, ranging from mental and behavioral health to care
coordination. The Committee noted that existing quality measures must be widely accepted and
impactful to evaluate the effectiveness and benefits of telehealth. While a number of measures were
identified through this work, the Committee acknowledged it is difficult to ascertain which would suffice
to assess whether telehealth is comparable to, or an improvement over, in-person care. The report and
conceptual framework for measuring telehealth serve as the foundation for future efforts by measure
developers, researchers, analysts, and others in the healthcare community to advance quality
measurement for telehealth.
lnteroperability
lnteroperability is the electronic sharing of health information and how that information is used. True
interoperability is a significant challenge to healthcare organizations for various reasons, including the
lack of a common, standard framework that reconciles the differences in data as well as the varying data
types. Additionally, healthcare organizations maintain incompatible products and systems, which are
unable to exchange the appropriate data within the organization and with partners in its community.
In 2017, NQF concluded a foundational, one-year project to develop a measurement structure and ideas
for measures to address current measurement gaps in interoperability. As a first step in developing this
framework, NQF conducted an environmental scan of references and research that provided insight into
the use of data to facilitate interoperability and the different methods of exchanging information,
including papers that focus on the use, effectiveness, or outcomes of health Information exchange (HIE).
Key findings from the scan included:
•
lnteroperability facilitates the exchange of data across numerous systems to support areas such
as public health, care coordination, patient engagement, and innovation
•
The availability of data with electronic health records (EHRs) and other systems, such as clinical
data registries, help support interoperability
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•
Facilitating greater interoperability supports decision making by providers and patients by
integrating data from various sources to present a unified view to facilitate data exchange as
well as establishing common formats for care coordination, quality reporting, and collaborative
care
•
lnteroperability has a significant impact on the accuracy of quality measurement in areas such as
cancer research, chronic disease management, and heart failure, as well as quality reporting by
using common data models and application programming interfaces.
NQF supplemented the findings of the environmental scan with key informant interviews with
candid<~tes from payer organizations, health information exchanges, integrated delivery systems, health
information exchange vendors, EHR/HIE vendors, informatics, and patient advocacy groups. These
interviews helped identify examples of the current realities of interoperability and exchange of data
across disparate systems; availability of data to facilitate interoperability; use of interoperability to
facilitate decision making; and the impact of interoperability on health/health-related outcomes and
processes.
NQF convened the multlstakeholder lnteroperablllty Committee to provide input and help guide the
creation of a framework. The committee developed a set of guiding principles to define key criteria for
measuring interoperability, including:
lnteroperability is more than EHR to EHR. That is, the focus of interoperabillty within a measurement
structure must extend beyond the concept of data exchange between two EHRs into one that
encompasses the diversity of data sources that capture patient and population data.
Stakeholder involvement. A broadly accessible, Interoperable system that incorporates data from
various sources would potentially enable diverse stakeholders to participate actively in using this data.
However, the impact of interoperable data affects various stakeholders in different ways, including
patients, providers, payers, and government.
Use of "outside data." The Committee clarifies that its concept of interoperability does not focus on the
ability of systems to gather outside data, but instead on the ability of systems to obtain and exchange
data accurately, effectively, efficiently, and in a usable form.
Differences due to setting and maturity. The use of interoperable data may also vary depending on the
setting (e.g., clinical, nonclinical) and its individualized needs, so measure concepts should be selected to
fit the setting. For example, measure concepts selected for nonclinical providers and settings that are
working to exchange health information electronically with community-based settings such as social
services might focus on the interoperability of social and environmental determinants of health data.
Various data types. Specifically, it will be critical for interoperability measures and measure concepts to
account for data that come from nonclinical sources that reside in multiple systems and in some cases
cannot yet be exchanged into an EHR or other clinical information system without compromising their
content and meaning.
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Based on the findings of the environmental scan, the key informant interviews, and its guiding
principles, the Committee ultimately proposed measuring key interoperability elements in four broad
categories (domains) and 15 subcategories (subdomains). These include:
1.
Exchange of electronic health information
•
Quality of data content
•
2.
Availability of electronic health information
•
Method of exchange
Usability of exchanged electronic health information
•
Accessibility
•
3.
Relevance
•
Comprehensibility
Application of exchanged electronic health information
•
4.
Human use
•
Computable
Impact of interoperability
•
Patient safety costs
•
Productivity
•
Care coordination
•
Improved processes and health outcomes
•
Patient and caregiver engagement
•
Patient and caregiver experience
NQF's interoperability project lays the groundwork for addressing the current gaps in the measurement
of interoperability, and is an important step in accomplishing national priorities for interoperability,
access, and use of health data.
Emergency Department Transitions of Care
Nearly 1 in 12 patients return to the emergency department (ED) or are hospitalized within three days of
an initial ED visit, and a third of those "revisits" occur at a different institution, according to a recent
study of 58 million patients discharged from EDs in six states. The study found that the revisit rate grew
from 2.7 percent within one day of discharge to 8.2 percent within three days of discharge and to 20
percent within 30 days of discharge. 133
Unclear, incomplete, or missing information during ED transitions in care between providers and
settings may lead to patient anxiety and uncertainty, avoidable resource use, or a worsening in the
patient's condition and potential harm. In addition, variability in communication during transitions from
one care setting to another may contribute to confusion among clinicians about the patient's severity of
condition and near-term care needs, duplicative tests, inconsistent patient monitoring, medication
errors, delays in diagnosis, and lack of follow through on referrals 134
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Currently, few measures address the quality of transitions of care into and out of an emergency
department (ED). However, ED visits often represent a critical juncture for a patient, and management
of these transitions is important to improve person-centered care, value, and cost efficiency.
To address the measurement gap, in 2016, NQF convened the multistakeholder Emergency Department
Quality of Transitions of Care Expert Panel to develop a measurement framework to prioritize measures
and measure concepts, as well as a set of guiding recommendations to help providers better manage
transitions of care. In a final report issued in August 2017, NQF recommended four domains, or broad
conceptual areas, and 11 subdomains, for measuring the quality of ED transitions. The four domains
include:
•
Provider information exchange. Communication and transfer of information between providers
that occurs during transitions of care into and out of the ED
•
Patient, family, and caregiver information exchange. Interactive and bidirectional
communication between patients (and their families, caregivers, or health proxies) and a
multidisciplinary, healthcare te?m (e.g., case manager, nurse, primary care physician)
•
Engagement of the broader community. The extent to which the broader community's
organizations, services, and information technology infrastructures are available and engaged to
support a quality transition of care into and out of the ED.
•
Achievement of outcomes. The extent to which quality, patient-centered ED transition of care
outcomes occur across patient episodes of acute care and within systems of care.
The Panel identified a set of priority measures and concepts that improve transitions for both patients
and providers, promote structures and processes to link clinical and nonclinical settings more effectively,
and measure outcomes to help monitor the development and implementation of systems to optimize
transitions.
The Panel also developed recommendations to promote policy change in support of measure
recommendations. For example, they suggest that EDs should expand infrastructure to support patientcentered ED transitions, such as by investing in EO-based care managers and social workers. Other
recommendations include enhancing health IT to enable data sharing, facilitating improvement through
payment models and other levers, and encouraging research to understand better patients who are at
highest risk for poor ED transition quality as well as poor outcomes related to these transitions.
Improving Diagnostic Quality and Safety
Diagnostic errors are the failure to establish or communicate an accurate and timely assessment of the
patient's health problem. 135 In the United States, at least 5 percent of adults seeking outpatient care
experience a diagnostic error.U" These errors contribute to nearly 10 percent of deaths annually, and up
to 17 percent of adverse hospital events. 137 Diagnostic errors persist across all healthcare settings and
can result in physical, psychological, or financial repercussions for the patient
To assist in reducing diagnostic harm, NQF in 2016 convened a multistakeholder expert Committee to
develop a structure for measuring diagnostic quality and safety and identify priorities for future measure
development. With guidance from the Committee, NQF staff conducted an environmental scan to
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identify measures related to diagnostic quality and safety and to inform the development of the
measurement framework. In a final report issued in September 2017, NQF recommends three domains
and 11 subdomains for the measurement of diagnostic quality and safety. These include:
•
Patients, families, and caregivers: patient experience and patient engagement
•
The diagnostic process: information gathering and documentation, information integration,
information interpretation, diagnostic efficiency, diagnostic accuracy, and follow-up
•
Organizational and policy opportunities: diagnostic quality improvement activities, access to
care and diagnostic services, workforce {e.g., the availability of appropriate staff)
The framework is intended to facilitate systematic identification and prioritization of measure gaps and
to help guide efforts to fill those gaps through measure development and endorsemen.t.
The Committee identified high-priority areas where measures are needed, including timeliness of
diagnosis, timeliness of test result follow-up, patient experience of diagnostic care, and communication
and hand-offs in transitions of care.
4
The report shares non measurement guidance from the Committee on issues that affect the ability of the
field to make improvements in diagnostic quality. For example, diagnostic accuracy can be advanced
significantly if EHRs are able to collect key diagnostic data and are interoperable within and across
systems. The Committee suggested engaging with medical specialty societies for input on measures for
conditions that are frequently misdiagnosed. The Committee also suggested that diagnostic safety and
quality become an important component of professional education.
Common Formats for Patient Safety
In 2008, AHRQ first released Common Formats to support structured reporting of safety events in
hospitals. These reporting techniques standardize the collection of patient safety event information
using common language, definitions, and reporting formats. Use of common data fields for event
reporting ensures that information shared with Patient Safety Organizations (PSOs) is consistent across
healthcare providers and can be aggregated to provide population-level insights into trends in adverse
events.
The public has an opportunity to comment on ali elements of the Common Formats modules using
commenting tools developed and maintained by NQF. An NQF Expert Panel reviews the public
comments and provides AHRQ feedback with the goal of improving the Common Formats modules.
In 2017, NQF continued to collect comments on all elements of the Common Formats, including the
most recent release, Hospital Common Formats Version 2.0. The NQF Expert Panel received updates
from AHRQ about ongoing development of new Common Formats, and AHRQ has signaled that it
expects to release an updated version of the Common Formats for Hospital Surveillance in early 2018.
NQF will post this new module for comments, which will then be reviewed by the Expert Panel for
feedback to AHRQ.
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Ambulatory Care Patient Safety
According to the Centers for Disease Control and Prevention, more than 83 percent of U.S. adults use
ambulatory care services annually through visits to primary care physicians, urgent care centers, dialysis
centers, and other outpatient providers. Although there has been tremendous research on patient
safety in inpatient settings, much less is known about effectively addressing safety issues in ambulatory
care. The 1999 Institute of Medicine publication, To Err is Human, raised awareness of the critical
importance of improving patient safety across the healthcare continuum and spurred a national call to
measure the quality of care across settings. With the increasing number of individuals seeking
outpatient care, it has never been more important to ensure patient safety in ambulatory care settings.
Building on NQF's body of work to improve quality and safety, including earlier work to set
measurement standards for ambulatory care/ 38 NQF has convened an advisory group to identify
measures and measure concepts for ambulatory care patient safety. This one-year project, funded by
the Agency for Healthcare Research and Quality (AHRQ), will inform the development of priority
measures to improve patient safety across ambulatory care settings for nonelderly patients (under age
65), and will help make care safer and more effective for millions of Americans. A report is expected in
September 2018.
VII.
Coordination with Measurement Initiatives by Other Payers
Section189D(b)(5)(A){i) of the Social Security Act mandates that the Annual Report to Congress and the
Secretary include a description of the implementation of quality and efficiency measurement initiatives
under this Act and the coordination of such initiatives with quality and efficiency initiatives implemented
by other payers.
Quality Measurement Support for the Medicaid Innovation Accelerator Program
Adding to NQF's efforts to improve healthcare for adults and children enroJJed in Medicaid, NQF in
September 2017 issued its first measure recommendations specificaHy for four high-cost, high-need
areas of care for the Medicaid population. These recommendations aim to support federal efforts to
help states tie payments-which totaled $553 billion in 2016-to improved value.
State Medicaid programs have faced numerous challenges in finding and using standardized measures
to evaluate quality within states and in comparing care delivered across states. The decentralized nature
of state quality programs has led to a proliferation of measures across states, contributing to a lack of
alignment and increased reporting burden for providers. Benchmarking also can be difficult, as similar
measures used in states may have different specifications.
The Medicaid Innovation Accelerator Program (lAP) supports states' ongoing efforts related to payment
and delivery reforms through targeted technical assistance to state Medicaid agencies across four
overlapping and Interrelated areas of focus: reducing substance use disorders, improving care for
beneficiaries with complex needs and high costs, promoting community integration through long-term
services and supports, and supporting physical and mental health integration. In addition, the program
works with states around key delivery system reform efforts In four functional areas: quality
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measurement, performance improvement, data analytics, and payment modeling and financial
simulations. 139
In 2016, under contract with CMS, NQF convened the multistakeholder Innovation Accelerator Project
Coordinating Committee and four Technical Expert Panels to identify and recommend measures that
address key quality issues in each of the lAP's four areas of focus. In a final report issued in September
2017, the Committee made the following measure recommendations to:
•
•
•
Reduce substance abuse disorders. 24 measures and five measure concepts, such as screening
and brief intervention, medication-assisted treatment, and continuity of care
Improve care for beneficiaries with complex care needs and high costs. 18 measures and one
measure concept, such as care utilization, follow-up care, and medication reconciliation
Promote community integration through long-term services and supports. 10 measures and
four measure concepts, such as quality of services, access to care, and medication reconciliation
Support physical and mental health integration. 30 measures and one measure concept, such
as coordination of treatment among providers, screening for physical and mental health
conditions, and care follow-up
The recommended measures and measure concepts are available for use by all state Medicaid agencies
and stakeholders to begin leveraging them for better, more efficient care regardless of participation in
the lAP.
Core Quality Measures Collaborative - Private and Public Alignment
Adding to NQF's efforts to encourage the use of more meaningful measures and reduce measure burden
on providers, NQF has provided technical assistance to the Core Quality Measures Collaborative (CQMC)
for several years. This initiative-led by the America's Health Insurance Plans (AHIP} and its member
plans' chief medical officers, and also involving CMS-brought together private- and public-sector
payers to reach consensus on core performance measures. 14() Representatives from national physician
organizations, employers, and consumer groups also participated in this effort. NQF self-funded its
participation in the CQMC.
The alignment of measure sets across payers will aid in:
•
Promotion of measurement that is evidence-based and can generate valuable information for
quality improvement;
•
Consumer decision making;
•
Value-based purchasing;
•
Reduction in the variability in measure selection; and
•
Decreasing providers' collection burden and costs.
Focusing initially on clinician-level measures used in the ambulatory care settings, the Collaborative in
2016 issued seven core measure sets in the following areas:
•
ACOs, PCMH, and primary care
•
Cardiology
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•
Gastroenterology
•
•
HIV and hepatitis C
Medical oncology
•
•
Obstetrics and gynecology
Orthopedics
CMS is already using measures from each of these core sets. 141 1n July 2017, the Collaborative published
an additional pediatrics core measure set consisting of nine measures intended for use at the provider
level for Individual clinicians or group practices. 142•143 Seven of the nine measures in the CQMC pediatric
set are also included in the Medicaid and CHIP Child Core Set, 144 for which NQF makes annual
recommendations. Although the CQMC pediatric set is intended for measurement at the healthcare
provider and group practice levels, measure alignment may help facilitate state-level Child Core Set
reporting and quality Improvement initiatives, according to CMS. 145
VIII.
Conclusion
NQF's work to improve health and healthcare is closely aligned with the national priorities of making
care safer, strengthening person and family engagement, promoting effective communication,
promoting effective prevention and treatment of chronic disease, working with communities to
promote best practices of healthy living, and making care affordable in partnership with public and
private healthcare stakeholders across the country.
In 2017, NQF completed or began work in key areas of importance to these national priorities. This work
includes projects to improve measurement of care quality in rural settings, reduce healthcare
disparities, address social determinants of health, and improve ways that the quality and outcomes of a
patient's care are accurately and fairly attributed to the responsible physician or other provider.
Additional projects provided national guidance on measurement structures to assess the quality of
telehealth, further progress toward interoperabillty, improve transitions of care from emergency
departments, and advance the quality and safety of clinical diagnoses.
Working with multistakeholder committees to build consensus on key strategies for performance
measurement and quality improvement, NQFs annual review and endorsement of healthcare
performance measures ultimately provides clinicians, hospitals, and other providers with the tools they
need to understand whether the care they provide their patients is optimal, and appropriate, and if not,
where to focus improvement efforts. NQF-endorsed measures serve to enhance healthcare value by
ensuring that consistent, high-quality performance data are available, which allows for comparisons
across providers as well as the ability to benchmark performance.
NQFs measure portfolio contains high-value measures across a variety of clinical and cross-cutting topic
areas. Forty-two percent of the measures in NQF's portfolio are outcomes measures. With continued
focus on high-value measures, NQF initiated efforts to prioritize meaningful measures and further
refined its measure portfolio, endorsing 120 new measures and removing endorsement for 109
measures across 18 quality measure endorsement projects in 2017.
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NQF's commitment to make measure endorsement more efficient, foster innovation, and enable greater
access to NQF's technical assistance was manifested in the significant improvements made in 2017 to its
measure review and endorsement process. Importantly, these efforts will reduce the measure
endorsement process to seven months, allow for two measure review cycles every year, and enhance
transparency through an expanded 15+ week opportunity for public comment for each endorsement
project. NQF also established a Scientific Methods Panel to provide methodological analyses of complex
measures.
NQF's Measure Applications Partnership (MAP) is a forum for the private and public sectors across the
care continuum where patients, clinicians, providers, purchasers, payers, and other stakeholders identify
and recommend the highest-value measures for federal program and provide strategic guidance across
these programs. Throughout its six years of annual review, MAP has worked toward the goal of lowering
costs while improving quality, making measurement meaningful for improvement while reducing
unnecessary administrative burden, and ensuring that patients and consumers get the information they
need to support their health care decision making. Importantly, in 2017, MAP constituted a new
workgroup to address the specific needs and challenges of rural providers and residents. MAP's 2017
work included a review of 71 unique performance measures under consideration for use in 16 federal
quality reporting and value-based payment programs covering clinician, hospital, and post-acute/longterm care settings. fn its 2017 guidance, MAP conducted a holistic review of the current measure sets
used in federal programs and recommended significant improvements to reduce measure burden.
During their 2017 deliberations, NQF standing committees that reviewed measures for endorsement or
conducted other activities related to improving NQF's measure portfolios discussed and identified more
than 100 measure gaps-areas in healthcare where high-value measures are too few or nonexistent-to
drive improvement. NQF's standing committees surfaced important measurement gaps in areas such as
palliative and end-of-life care, behavioral health, pediatric care, and patient safety. MAP also identified
measure gaps to assess care and improvement in federal healthcare programs, and NQF's Medicaid Task
Forces and Workgroup noted gaps in the core measure sets that states use to assess care for adults and
children on Medicaid.
fn 2018, NQF looks forward to continuing work that drives increased use of high-value quality
measurement across settings of care, improves the usability and implementation of eMeasures, and
furthers a portfolio of effective and impactful measures that public and private payers, providers, and
patients can rely upon to improve health and healthcare value.
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IX.
1
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Appendix A: 2017 Activities Performed Under Contract with HHS
1 Recommendations on the National Quality Strategy and Priorities
Description
Output
Status
Notes/Scheduled or Actual
Completion Date
Eliminating healthcare disparities
and achieving health equity
Roadmap for reducing health and
healthcare disparities through policy
levers
Completed
Final report published
September 2017
Food Insecurity and Housing
lnstabHity A framework for
Medicaid programs to address
social determinants of health
Guidance for state Medicaid programs
to make strategic investments in the
collection and use of social determinants
of health data
Completed
Final report completed
December 2017
Annual review and update of
quality measures for adults
enrolled in Medicaid
Annua I input on the Core Set of Health
Care Quality Measures for Adults
Enrolled in Medicaid
Completed
Completed August 2017
Annual review and update of
quality measures for children
enrolled in Medicaid
Annua I input on the Core Set of Health
Care Quality Measures for Chlldren
enrolled in Medicaid.
Completed
Completed August 2017
Annual review and update of
quality measures for the dual·
eligible \Medicare-Medicaid)
population
Annual input on the Dual Eligible
Beneficiaries Family of Measures.
Completed
Completed August 2017
Status
Notes/Scheduled or Actual
Completion Date
2. Quality and Efficiency Measurement Initiatives
Completed in 2017
Description
All-Cause Admissions and
Readmissions 2015·2017
Set of endorsed measures for all-cause
admissions and readmissions
2015·2017
completed
final report published April
2017
All Cause Admissions and
Readmissions 2017
Set of endorsed measures for all-cause
admissions and readmissions
2017
completed
Final report published
September 2017
Behavioral Health 2016-2017
Set of endorsed measures for behavioral
health
2016-2017
completed
final report published
August2017
Cancer 2015·2017
Set of endorsed measures for cancer
care
2015-2017
completed
Final report published
January 2017
Cardi!>Vascular Conditions 2016·
2017
Set of endorsed measures for
cardiovascular conditions
2016-2017
completed
Final report published
February 2017
Care Coordination Measures
2016-2017
Set of endorsed measures for care
coordination
2016-2017
completed
Final report published
August2017
completed
Final report published
August2017
7
completed
Final report published
September 2017
Set of endorsed measures for health and
well-being
2015-2017
completed
2017
Set of endorsed measures for infectious
2016-2017
completed
Final report published
August2017
Measure Review 2017
Health and Well-Being 2015·2017
Infectious Disease 2016-2017
disease
Final report published April
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Description
Output
Status
Musculoskeletal Off-Cycle
Measure Review 2017
No measures for musculoskeletal
conditions endorsed
2017
completed
Final report published July
2017
Palliative and EOL Care Off-Cycle
Measure Review 2017
One measure endorsed for palliative and
end-of-life care
2017
completed
Final report published
September 2017
Patient- and Family-Centered
Care 2015-2016
Set of endorsed measures for patientand family-centered care
2015-2016
completed
Final report published
January 2017
Patient Safety 2016
Set of endorsed measures for patient
safety
2016
completed
Final report published March
2017
Patient Saf<"ty Off-Cycle Measure
Review 2017
Measures considered but not endorsed
2017
Final report published July
2017
Pediatric Performance Measures
2017
Set of endorsed measures
Final report published
August 2017
Renal Conditions 2015-2017
Set of endorsed measures for renal
conditions
Final report published
February 2017
Surgical Procedures 2015-2017
Set of endorsed measures for su rgi
procedures
completed
Description
Output
Status
Notes/Scheduled or Actual
Completion Date
All-Cause Admissions and
Readmissions
Set of endorsed measures for all-cause
admissions and readmissions
In progress
Final report expected July
2018
Behavioral Health and Substance
Use
Set of endorsed measures for behavioral
health
In progress
Final report expected July
2018
cancer
Set of endorsed measures for cancer
In progress
35391
Final report expected July
Completion Date
Final report published April
2017
Started in 2017
2018
care
cardiovascular
Set of endorsed measures for
cardiovascular conditions
In progress
Final report expected July
2018
Cost and Efficiency
Set of endorsed measures for cost and
resource use
In progress
Final report expected July
2018
Geriatric and Palliative Care
Set of endorsed measures for geriatric
and palliative care
In progress
Neurology
Set of endorsed measures for
neurological conditions
In progress
Final report expected July
2.018
Patient Experience and Function
Set of endorsed measures for patient
experience and function
In progress
Final report expected July
2018
Patient Safety
Set of endorsed measures for patient
safety
In progress
Final report expected July
2018
Perinatal and Women's Health
Set of endorsed measures for perinatal
and women's health
In progress
Final report expected July
2018
Prevention and Population
Health
Set of endorsed measures for prevention
and population health
In progress
Final report expected July
2018
Primary care and Chronic Illness
Set of endorsed measures for primary
care and chronic illness
In progress
Final report expected July
2018
Renal
Set of endorsed measures for renal
conditions
In progress
Final report expected July
2018
Surgery
Set of endorsed measures for surgical
procedures
In progress
Final report expected July
2018
Final report expected July
2018
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3 Stakeholder Recommendations on Quality and Efficiency Measures and National Priorities
Description
Output
Status
Notes/Scheduled or Actual
Completion Date
Recommendations for measures
to be implemented through the
federal ndemaking process for
public reporting and payment
Measure Applications Partnership prerulemaklng recommendations on
measures under consideration by HHS
for 2017 ru lema king
Completed
Completed February 2017
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Appendix B: Medicaid Task Forces and Workgroup Ro5ters
Adult Task Force
CHAIR {VOTING)
Harold Pincus, MD
ORGANIZATIONAl MEMBERS (VOTING)
National Rural Health Association
Diane Calm us, JD
Centene Corporation
Mary Kay Jones, MPH, BSN, RN, CPHQ
American Association of Nurse Practitioners
Sue Kendig, JD, WHNP-BC, FAANP
Association for Community Affiliated Health Plans
Deborah Kilstein, RN, MBA, JD
National Association of Medicaid Directors
Rachel La Croix, PhD, PMP
American Academy of Family Physicians
Roanne Osborne-Gaskin, MD, MBA, FAAFP
Consortium for Citizens with Disabilities
Clarke Ross, DPA
Academy of Managed Care Pharmacy
Marissa Schlaifer, RPh, MS
FEDERAL GOVERNMENT MEMBERS
(NON-VOTING, EX OFFICIO)
Health Resources and Services Administration {HRSAI
&uma Nair, MS, RD
Substance Abuse and Mental Health Services Administration (SAMHSA)
lisa Patton, PhD
Centers for Medicare & Medicaid Services (CMS)
Marsha Smith, MD
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Child Task Force
CHAIRS (VOTING)
Richard Antonelli, MD
ORGANIZATIONAL MEMBERS (VOTING)
American Academy of Pediatrics
Terry Adirim, MD, MPH
American Nurses Association
Gregory Craig, MS, MPA
America's Essential Hospitals
Kathryn Beattie, MD
American Academy of Family Physicians
Roanne Osborne-Gaskin, MD, MBA, FAAfP
Association for Community Affiliated Plans
Deborah Kilstein, RN, MBA, JD
Aetna
Amy Richardson, MD, MBA
Centene Corporation
Amy Poole-Yaeger, MD
Children's Hospital Association
Andrea Benin, MD
National Association of Medicaid Directors
Rachella Croix, PhD
National Partnership for Women and Families
carol Sakala, PhD, MSPH
Patient-Centered Primary Care Collaborative
Ann Greiner, M UP
INDIVIDUAL SUBJECT MATTER EXPERT MEMBERS (VOTING)
Kim Elliot, PhD, CPHQ
FEDERAl GOVERNMENT MEMBERS
(NON-VOTING, EX OFFICIO)
Agency for Healthcare Research and Quality
Kamila Mrstry, PhD, MPH
Centers for Medicare & Medicaid Services
Marsha Smith, MD, MPH, FAAP
Health Resources and Servi<es Administration
Suma Nair, MS, RD
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Dual Eligible Beneficiaries Workgroup
CO-CHAIRS (VOTING)
Jennie Chin Hansen, RN, MS, FAAN
Mlcnael Monson, MPP
Nancy Hanrahan, PhD, PN, FAAN
llnactlve March-May, 20171
ORGANIZATIONAL MEMBERS (VOJING)
AARP Public Polley Institute
Susan Reinhard, RN, PhD, FAAN
American Medical Directors Association
Gwendolen Buhr, MD, MHS, Med, CMD
American Occupational Therapy Association
Joy Hammel, PhD, OTR/L, FAOTA
Association for Community Affiliated Health Plans
Christine Aguiar Lynch, MPH
Centene Corporation
Michael Monson, MPP
Consortium for Citizens with Disabilities
E. Clarke Ross, DPA
Homewatch CareGivers
Jennifer Ramona
!Care
Thomas H. Lutzow, PhD, MBA
Medicare Rights Center
Joe Baker, JD
National Association of Medicaid Directors
Alice Lind, BSN, MPH
National Association of Social Workers
Joan Levy Zlotnik, PhD, ACSW
New Jersey Hospital Association
Aline Holmes, ONP, MSN, RN
SNPAIIIance
Richard Bringewatt
INDIVIDUAl SUBJECT MATTER EXPERTS (VOTING)
Alison Cuellar, PhD
K. Charlie Lakin, PhD
Pamela Parker, MPA
Kimberly Rask, MD, PhD
FEDERAL GOVERNMENT LIASONS (NON-VOTING}
Administration for Community living (ACLI
Eliza Bangit, JD, MA
CMS Medicare-Medicaid Coordination Office
Stacey Lytle, MPH
Office of tne Assistant Secretary for Planning and Evaluation
D.E.B. Potter, MS
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Appendix C: Scientific Methods Panel Roster
Chairs
David Cella, PhD
Professor, Northwestern University
Karen Joynt Maddox, MO, MPH
Assistant Professor, Washington University School of Medicine
Members
J. Matt Austin, PhD
Assistant Professor, Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine
Bijan Borah, MSc, PhD
Associate Professor, Mayo Clinic
John Bott, MBA, MSSW
Manager, Healthcare Ratings, Consumer Reports
Lacy Fabian, PhD
Lead Healthcare Evaluation Spe<:iallst, The MITRE Corporation
Marybeth Farquhar, PhD, MSN, RN
Vice President, Quality, Research & Measurement, URAC
Jeffrey Geppert, EdM, JD
Senior Research leader, Battelle Memorial Institute
Paul Gerrard, BS, MD
Associate Medical Director Physical Medicine ;md Rehabilitation, New England Rehabilltation Hospitals of Portland (HealthSouth, Inc.)
Laurent Glance, MD
Professor and Vice-Chair for Research, University of Rochester School of Medicine and Dentistry
Stephen Homer, RN, BSI\l, MBA
Vice President Clinical Analytics, HCA, Inc.
Sherrie Kaplan, PhD, MPH
Professor of Medicine, Vice Chancellor for Health care Measurement and Evaluation, UC Irvine School of Medicine
Joseph Kunisch, PhD, Rl\l-BC, CPHQ,
Enterprise Director of Clinical Quallty Informatics, Memorial Hermann Health System
Paul Kurlansky, MD
Associate Professor of Surgery I Associate Director, Center for Innovation and Outcomes Research I Director of Research, Recruitment
and CQI, Columbia University, College of Physicians and Surgeons I Columbia Hear!Source
Zhenqiu Lin, PhD
Director of Data Management and Analytics, Vale-New Haven Hospital
Jack Needleman, PhD
Professor, University of California Los Angeles
David 1\lerenz, PhD
Director, Center for Health Policy and Health Services Research, Henry Ford Health System
Eugene Nutcio, PhD
Assistant Professor, University of Colorado, Anschutz Medical Campus
Jennifer Perloff, PhD
Scientist and Deputy Director at the Institute of Healthcare Systems, Brandeis University
Sam Simon, PhD
Senior Researcher, Mathematica Policy Research
Michael Stoto, PhD
Professor of Health Systems Administration and Population Health, Georgetown University
Christie Telgland, PhD
Vice President, Advanced Analytics, Avalere Health
Ronald Walters, MD, MBA, MHA, MS
Associate Vice President of Medical Operations and Informatics, University of Texas MD Anderson Cancer Center
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Susan White, PliO, RHIA, CHDA
Administrator -Analytics, The James Cancer Hospital at The Ohio State University Wexner Medical Center
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Appendix D: NQF-Endorsed Measures Adjusted for Social Risk
2842
Family Experiences with Coordination of Care {FECC)-1:
Has Care Coordinator
Respondent education
2843
Family Experiences with Coordination of Care {FECC)-3:
Care coordinator hel
to obtain
services
Respondent education
2844
Family Experiences with Coordination of Care {FECC)-5:
Care coordinator asked about concerns and health
Respondent education
2845
Family Experiences with Coordination of Care {FECC)-7:
Care coordinator assisted with
list service referrals
Respondent education
2846
Family Experiences with Coordination of Care {FECC)-8:
Care coordinator was knowledgeable, supportive and
Respondent education
Respondent education
Respondent education
Respondent education
Dual eligible status
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Appendix E: MAP Measure Selection Criteria
The Measure Selection Criteria (MSC) are intended to assist MAP with identifying characteristics that are
associated with ideal measure sets used for public reporting and payment programs. The MSC are not
absolute rules; rather, they are meant to provide general guidance on measure selection decisions and
to complement program-specific statutory and regulatory requirements. Central focus should be on the
selection of high-quality measures that optimally address the National Quality Strategy's three aims, fill
critical measurement gaps, and increase alignment. Although competing priorities often need to be
weighed against one another, the MSC can be used as a reference when evaluating the relative
strengths and weaknesses of a program measure set, and how the addition of an individual measure
would contribute to the set The MSC have evolved over time to reflect the input of a wide variety of
stakeholders.
To determine whether a measure should be considered for a specified program, the MAP evaluates the
measures under consideration against the MSC. MAP members are expected to familiarize themselves
with the criteria and use them to indicate their support for a measure under consideration.
1. NQF-endorsed measures are required for program measure sets, unless no relevant
endorsed measures are available to achieve a
Demonstrated by a program measure set that contains measures that meet the NQF endorsement
criteria, Including importance to measure and report, scientific acceptability of measure properties,
feasibflity, usability and use, and harmonization of competing and related measures
Subcriterion 1.1
Measures that are not NQF-endorsed should be submitted for endorsement if
selected to meet a specific program need
Subcriterion 1.2
Measures that have had endorsement removed or have been submitted for
endorsement and were not endorsed should be removed from programs
Subcriterion 1.3
Measures that are in reserve status (i.e., topped out) should be considered for
removal from programs
2. Program measure set adequately addresses each of the National Quality Strategy's
three aims
Demonstrated by a program measure set that addresses each of the National Quality Strategy (NQS)
aims and corresponding priorities. The NQS provides a common framework for focusing efforts of diverse
stakeholders on:
Sub~riterion
2.1
Subcriterion 2.2
Subcriterion 2.3
Better care, demonstrated by patient- and famlly-centeredness, care
coordination, safety, and effective treatment
Healthy people/healthy communities, demonstrated by prevention and welfbelng
Affordable care
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3. Program measure set is responsive to specific program goals and requirements
Demonstrated by a program measure set that is '1it for purpose" for the particular program
Subcrlterlon 3.1
Program measure set includes measures that are applicable to and
appropriately tested for the program's intended care setting(s}, level{s) of
analysis, and popu/ation(s)
Subcriterion 3.2
Measure sets for public reporting programs should be meaningful for
consumers and purchasers
Subcriterion 3.3
Measure sets for payment incentive programs should contain measures for
which there is broad experience demonstrating usability and usefulness (Note:
For some Medicare payment programs, statute requires that measures must
first be implemented in a public reporting program for a designated period)
Subcriterlon 3.4
Avoid selection of measures that are likely to create significant adverse
consequences when used in a specific program
Subcriterion 3.5
Emphasize inclusion of endorsed measures that have eCQM specifications
available
4. Program measure set includes an appropriate mix of measure types
Demonstrated by a program measure set that includes an appropriate mix of process, outcome,
experience of care, cost/resource use/appropriateness, composite, and structural measures necessary for
the specific program
Subcriterion 4.1
In general, preference should be given to measure types that address specific
program needs
Subcrlterion 4.2
Public reporting of program measure sets should emphasize outcomes that
matter to patients, including patient· and caregiver-reported outcomes
Subcriterlon 4.3
Payment program measure sets should include outcome measures linked to
cost measures to capture value
5. Program measure set enables measurement of person- and family-centered care and
services
Demonstrated by a program measure set that addresses access, choice, self-determination, and
community integration
Subtriterlon 5.1
Measure set addresses patient/family/caregiver experience, including aspects
of communication and care coordination
Subcriterion 5.2
Measure set addresses shared decision making, such as for care and service
planning and establishing advance directives
Subcriterion 5.3
Measure set enables assessment of the person's care and services across
providers, settings, and time
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6. Program measure set includes considerations for healthcare disparities and cultural
Demonstrated by a program measure set that promotes equitable access and treatment by considering
healthcare disparities. Factors include addressing race, ethnicity, socioeconomic status, language,
gender, sexual orientation, age, or geographical considerations (e.g., urban vs. rural). Program measure
set also can address populations at risk for healthcare disparities (e.g., people with behavioral/mental
illness).
Subcriterion 6.1
Program measure set includes measures that directly assess healthcare
disparities (e.g., interpreter services)
Subcriterion 6.2
Program measure set includes measures that are sensitive to disparities
measurement (e.g., beta blocker treatment after a heart attack), and that
facilitate stratification of results to better understand differences among
vulnerable populations
7. Program measure set promotes parsimony and alignment
Demonstrated by a program measure set that supports efficient use of resources for data collection and
reporting, and supports alignment across programs. The program measure set should balance the
degree of effort associated with measurement and its opportunity to improve quality.
Subcriterion 7.1
Program measure set demonstrates efficiency (i.e., minimum number of
measures and the least burdensome measures that achieve program goals)
Subcriterion 7.2
Program measure set places strong emphasis on measures that can be used
across multiple programs or applications (e.g., Physician Quality Reporting
System, Meaningful Use for Eligible Professionals, Physician Compare)
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Appendix F: Federal Quality Reporting and Performance-Based Payment Programs
Considered by MAP
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Ambulatory Surgical Center Quality Reporting
End-Stage Renal Disease Quality Improvement Program
Home Health Quality Reporting
Hospice Quality Reporting
Hospital Acquired Condition Payment Reduction (ACA 3008)
Hospital Inpatient Quality Reporting (IQR) Program
Hospital Outpatient Quality Reporting (OQR) Program
Hospital Readmission Reduction Program
Hospital Value-Based Purchasing
Inpatient Psychiatric Facility Quality Reporting Program
Inpatient Rehabilitation Facility Quality Reporting
Long-Term Care Hospital Quality Reporting
Medicaid Adult and Child Core Measure Sets
Medicare Shared Savings Program
Merit-Based Incentive Payment System
Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting
SkiHed Nursing Facility Quality Reporting Program
Skilled Nursing Facility Value-Based Purchasing Program
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Appendix G: MAP Structure, Members, Criteria for Service, and Rosters
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, 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 Coordinating Committee
COMMITTEE CO-CHAIRS (VOTING)
Charles Kahn, 111, MPH
Federation of American Hospitals
Harold Pincus, MD
New York Presbyterian/Columbia University
ORGANIZATIONAL MEMBERS (VOTING)
Academy of Managed Care Pharmac.y
Marissa Schlaifer, RPh, MS
AdvaMed
Steven Brotman, MD, JD
AFL-CIO
Shaun O'Brien, J D
Amerl<:a's Health Insurance Plans
Aparna Higgins, MA
American Board of Medical Specialties
R. Barrett Noone, MD, FACS
American Academy of Family Physl<:ians
Amy Mullins, MD, FAAFP
American College of Physicians
Amir Qaseem, MD, PhD, MHA
American College of Surgeons
Bruce Hall, MD, PhD, MBA, fACS
American HealthCare Association
David Gifford, MD, MPH
American Hospital ASSOtiation
Rhonda Anderson, RN, DNSc, FAAN
American Medical ASsoclatl<m
Carl Sirio, MD
American Nurses AsSOtlatlon
Mary Beth Bresch White
AMGA
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Samuel Lin, MD, PhD, MBA, MPA, MS
Blue Cross and Blue Shield Association
Carole Flamm, MD, MPH
Consumers Union
John Bott, MSSW, MBA
Healthcare Financial Management Association
Richard Gundling, FHFMA, CMA
Maine Health Management Coalition
Brandon Hotham, MPH
The Joint Commission
David Baker, MD, MPH, fACP
The Leapfrog Group
leah Binder, MA, MGA
National Alliance for Caregiving
Gail Hunt
National Association of Medicaid Directors
foster Gesten, MD, FACP
National Buslness Group on Health
Steven Wojcik, MA
National Committee for Quality Assurance
Marv Barton, MD
National Partnership for Women & Families
Carol Sakala, PhD, MSPH
Network for Regional Healthcare Improvement
Chris Queram, MS
Pacific Business Group on Health
William Kramer, MBA
Pharmaceutical Research and Manufacturers of America (PhRMA)
Jennifer Bryant, MBA
Providence Health and Services
Ari Robicsek, MD
INDIVIDUAl SUBJECT MATTER EXPERTS {VOTING)
Richard Antonelli, MD, MS
Doris Lott, MD, MPH
FEDERAL GOVERNMENT LIAISONS (NON-VOTING)
Agency for Healthcare Research and Quality (AHRQ)
Nancy J, Wilson, MD, MPH
Centers for Disease Control and Prevention (CDC)
Chesley Rfchards, MD, MH, FACP
Centers for Medicare & Medicaid Services iCMS)
Patrick Conway, MD, MSc
Office of the National Coordinator for Health Information Technology (ONC)
David Hunt, MD, FACS
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MAP Rural Health Workgroup
CO-CHAIRS (VOTING)
Aaron Garman, MD
Ira Moscovlce, PhO
ORGANIZATIONAL MEMBERS (VOTING)
Alllant Health Solutions
Kimberly Rask, MD, PhD, FACP
American Academy of Family Physicians
David Schmitz, MD, FAAfP
American Academy of PAs
Daniel Coli, MHS, PA-C, DFAAPA
American College of Emergency Physicians
Steve Jameson; MD
American Hospital Association
Stephen Tahta, MD
Geisinger Health
Karen Murphy, PhD, RN
Health Care Service Corporation
Shelley Carter, RN, MPH, MCRP
Intermountain Healthcare
Mark Greenwood, MD
Michigan Center for Rural Health
Crystal Barter, MS
Minnesota Community Measurement
Julie Sonier, MPA
National Association of Rural Health Clinics
Sill Finerfrock
National Center for Frontier Communities
Susan Wilger, MPA
National Council for Behavioral Health
Sharon Raggio, LPC, LMFT, MBA
National Rural Health Association
Brock Slabach, MPH, FACHE
National Rural Letter Carriers' Association
Cameron Deml
RUPRI Center for Rural Health Polley Analysis
Keith Meuller, PhD
Rural Wisconsin Health Cooperative
Tim Size, MBA
Truven Health Analytics LLC/IBM Watson Health Company
Cheryl Powell, MPP
INDIVIDUAL SUBJECT MATTER EXPERTS (VOTING)
John Gale, MS
Curtis lowery, MD
Melinda Murphy, RN, MS
Ana Verzone, fNP, C:NM
Holly Wolff
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FEDERAL GOVERNMENT liAISONS {NONNOTING)
Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services (CMS)
Susan Anthony DrPH
Federal Office of Rural Health Polley, OHHS/HRSA
Craig Caplan
Indian Health Service
Juliana Sadovich PhD, RN
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MAP Clinician Workgroup
CO-CHAIRS (VOTING)
Bruce Bagley, MD
Arm; Moyer
Eric Whitacre, MD, FAtS {substitute for Amy Moyer during In-Person)
ORGANIZATIONAl MEMBERS (VOTING)
American Academy of Ophthalmology
Scott Friedman, MD
American Academy of Pediatrics
Terry Adirim, MD, MPH, FAAP
American Association of Nurse Practitioners
Diane Padden, PhD, CRNP, FAANP
American College of Cardiology
Steven A. Farmer, MD, FACC .
American College of Radiology
David J. Seidenwurm, MD
Anthem
Kevin Bowman, MD, MB, MPH
Association of American Medical Colleges
Janis Orlowski, MD
Carolina's Healthcar~; System
Scott Furney, MD, FACP
Consumers' CHECKBOOK
Robert Krughoff, JD
Council of Medical Specialty Societies
Norman Kahn MD, EVP/CEO, CMSS
Health Partners, Inc.
Beth Averbeck, MD
National Center for lnterprofesslonall'ractice and Education
James Pacaia, MD, MS
Pacific Business Group on Health
Stephanie Glier, MPH
Patient-Centered
Primary Care Collaborative
Marc! Nielsen, PhD, MPH
Primary Care
Information Project
Winfred Wu, MD, MPH
St. Louis Area Business Health Coalition
Patti Wahl, MS
INDIVIDUAL SUBJECT MATTER EXPERTS (VOTING)
Dale Shafler, MPA
Michael Hasset, MD, MPH Eric Whitacre, MD, FACS Leslie Zun, MD
FEDERAL GOVERNMENT LIAISONS (NON.VOTING)
Centers for Disease Control and Prevention (CDC)
Peter Brlss, MD, MPH
Centers for Medicare & Medicaid Services (CMS)
Pierre Yong, MD, MPH, MS
Health Resources and Services Administration (HRSA)
88
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DUAlS WORKGROUP LIAISON (NON~VOTING)
Consortium for Citizens w/ Dlsabllll:les
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MAP Hospital Workgroup
WORKGROUP CHAIRS (VOTING)
Christie Upshaw Travis, MSHHA {Co-Chair)
Ronald S. Walters, MD, MBA, MHA, MS (Co-Chair)
ORGANIZATIONAL MEMBERS (VOTING)
America's Essential Hospitals
David Engler, PhD
American Hospital Association
Nancy Foster
Baylor Scott & White Health (BSWH)
Marlsa Valdes, RN, MSN
Blue Cross Blue Shield of Massachusetts
Wei Ying, MD, MS, MSA
Children's Hospital Association
Andrea Benin, MD
Kidney Care Partners
Allen Nissenson, MD
Gelsinger Health Systems
Heather Lewis, RN
Medtronlc-Mlnimally Invasive Therapy Group
Karen Shehade, MBA
Mothers against Medical Error
Jennifer Eames Huff, MPH
National Association of Psychiatric Health Systems (NAPHS)
Frank Ghinassi, PhD, ABPP
National Rural Health Association
Brock Slabach, MPH, FACHE
Nursing Alliance for Quality Care
Kimberly Glassman, PhD, RN, NEA-BC, FAAN
Pharmacy Quality Alliance
Woody Eisenberg, MD
Premier, Inc,
Mimi Huizinga, MD
Project Patient Care
Martin Hatlle, JD
Service Employees International Union
Sarah Nolan
The Society of Thoracic Surgeons
Jeff Jacobs, MD
University of Michigan
Marsha Manning
INDIVIDUAL SUBJECT MATTER EXPERTS (VOTING)
Gregory Alexander, PhD, RN, FAAN
Elizabeth Evans, DNP
Lee Fleisher, MD
Jack Jordan
R. Sean Morrison, MD
Ann Marie Sullivan, MD
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lindsey Wisham, BA, MPA
FEDERAl GOVERNMENT liAISONS (NON-VOTING)
Agency for Heatthcare Research and Quality (AHRO.)
Pamela Owens, PhD
Centers for Disease Control and Prevention (CDC)
Daniel Pollock, MD
Centers for Medicare & Medicaid Services (CMS)
Pierre Yong, MD, MPH
DUAl ELIGIBlE BENEFICIARIES WORKGROUP LIAISON (NON-VOTING)
New Jersey Hospital Association
Aline Holmes
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MAP Post-Acute Care/Long-Term Care Workgroup
CO-CHAIRS (VOTING)
Gerri Lamb, RN, PhD
Debra Saliba, MD, MPH
ORGANIZATIONAL MEMBERS (VOTING)
Aetna
Alena Baquet-Simpson, MD
AMOA- The Society for Post-Acute and Long-Term Care Medicine
Dheeraj Mahajan, MD, CMD
American Occupational Therapy Association
Pamela Roberts, PhD, OTR/L, SCFES, CPHQ, FAOTA
American Physical Therapy Association
Heather Smith, PT, MPH
Caregiver Action Network
Lisa Wlnstel, MAM
HealthSouth Corporation
Lisa Charbonneau, DO, MS
Johns Hopkins University School of Medicine
Bruce Leff, MD
Kindred Healthcare
Sean Muldoon, MD
National Association of Area Agencies on Aging
Sandy Markwood, MA
The National Consumer Voice for Quality Long-Term Care
Robyn Grant, MSW
National Hospice and Palliative Care Organization
Carol Spence, PhD
National Partnership for Hospice Innovation
Theresa Schmidt, MA
National Pressure Ulcer Advisory Panel
Arthur Stone, MD, CMD
National Transitions of Care Coalition
James Lett, U, MD, CMD
Visiting Nurses Assodation of America
Dartielle Pierotti!!, RN, PhD, CENP, AOCN, CHPN
FEDERAL GOVERNMENT LIAISONS (NON-VOTING)
Centers for Medicare & Medicaid Services (CMS)
Alan levitt, MD
Office of the National Coordinatorfor Health Information Technology (ONC)
Elizabeth Pal~ma Hall, MIS, MBA, RN
Substance Abuse and Mental Health Services Administration (SAMHSAI
Usa Patton, PhD
SNPAIIIance
Richard Bringewatt
INDIVIDUAl SUBJECT MATTER EXPERTS (VOTING)
Kim Elliott, PhD, CPHQ
Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
Paul Mulhausen, MD, MHS
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Cl!rcl!ne Fife, PhD, CPH
Eugene Nut(ic, PhD
Thomas Von Sternberg, MD
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Appendix H: Identified Gaps by NQF Measure Portfolio
In 2017, NQF's standing committees identified the following measure gaps-where high-value measures
are too few or non-existent to drive improvement-across topical areas for which measures were
reviewed for endorsement.
Behavioral Health
•
•
•
•
•
•
Outcome measures for psychotic disorders, including schizophrenia
Overprescription of opiates
Setting-specific measures (e.g., jails)
Proximal outcome measures
Measures that focus on substance use disorders in the primary care setting
Composite measures that incorporate myriad mental illnesses (e.g., bipolar disorder,
depression, and schizophrenia) rather than separate screening measures for each illness
•
•
Patient-reported outcome measures
Measures that encompass multiple settings to better assist in the push towards integrated
behavioral health and physical health
Measures that examine the period oftime between screening and remission
Measures that address access to behavioral health facilities, or lack thereof
Measures that focus not only on treatment and prevention but also on recovery
•
•
•
Cancer
•
•
•
Prostate and thoracic cancer measures that range from screening to advanced disease
Oral chemotherapy compliance measures
Outcome measures including risk-adjusted morbidity and mortality measures
Care Coordination
•
•
•
•
•
•
•
Linkages and synchronization of care and services
A comprehensive assessment process that incorporates the perspective of a care recipient and
his care team
Shared accountability within a care team
rather than measures that address care within silos
Measures that evaluate
Outcome measures
Capturing data and documenting linkages between a patient's need/goal and relevant
interventions in a standardized way and linked to relevant outcomes
Measures that are evidence-based
Cost and Resource Use
•
•
•
•
Total per capita cost measure for Medicare patients
Measures for post-acute care settings, including home health, skilled nursing facilities, and longterm acute care
Measures that examine spending for high-cost, high-risk acute patients, including patients with
multiple chronic diseases
Measures that examine resource use across the patient episode of care-spanning across care
settings, providers, and time
Health and Well-Being
•
Measures that detect differences in quality across institutions or in relation to certain
benchmarks, but also differences in quality among populations or social groups.
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•
•
•
•
•
•
Measures that assess access to care
Measures that assess environmental factors
Measures that address food insecurity
Measures that address language and literacy
Measures that address health literacy
Measures that address social cohesion
Infectious Disease
•
•
Measures that underscore the value of infectious disease (JD) consultation, which studies have
shown to improve outcomes. For example, the rate of ID consults in those with Staphylococcus
aureus bacteremia, cryptococcal infection, and HIV patients on ART.
HPV screening in females with HIV
Palliative and End of Life Care
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Screening for depression, anxiety, etc.
Access to nutritional support
Use of decisional conflict scale
Dying in preferred site of death
Assessment of psychosocial and spiritual issues/needs
Provider Orders for Life-Sustaining Treatment (POLST) form completion according to patient
values
depression, complicated bereavement, etc.)
Assessing family/caregivers for risk
Preservation of functional status
Total pain {including spiritual pain)
Psychosocial health
Unmet need (e.g., through Integrated Palliative Care Outcome Scale (iPOS) instrument)
Quality of life {e.g., through single item self-report of quality of life as in McGill Quality of Life
Survey)
Goal-concordance
Shared decision making
Comfort with decisions that are made (e.g., less decisional conflict)
Patient/family engagement
Values conversation that elicits goals of care
Good communication (e.g., prognosis, health literacy, clarity of goals for all parties)
Unwanted care/care that is not goal-concordant
Symptomatology due to use of excess/poor value medications/ interventions
Unmet psychosocial and spiritual need
Medication reconciliation
Safe medication use
Safe medication disposal
Feeding tube placement in dementia patients
Discussion about and potential discontinuation of available interventions in terminal patients
{e.g., statin, aspirin, multivitamins, memory drugs, lCDs, CPR, chemo in last 2 weeks)
Caregiver support
Caregiver stress
Good communication (early, open/shared)
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•
•
•
•
•
•
•
•
•
•
•
•
•
Basic caregiver skills training provided (e.g., how to lift patient without injury to caregiver's back,
changing sheets when patient is bedridden, etc.)
Potentially avoidable EO visits and hospitalizations
Proportion of elderly chronic kidney disease patients with multiple comorbidities who were
started on dialysis
Proportion of dialysis patients admitted to ICU in last 30 days of life
Percentage of elderly patients with chronic kidney disease and multiple comorbidities admitted
to an "active medical management without dialysis" pathway of care
Geographic access to hospice and palliative care (both hospital and community)
Access to home and community-based services
Time to palliative care consult or timeliness of palliative care consultation (>48 hours prior to
death)
Access to specialty palliative care team
Nursing load or chaplain load
Number of patients in a hospice or palliative care program who are getting chaplain visits
Standard/minimum service offerings
Materials offered at appropriate education levels/languages
Patient Safety
•
•
•
•
•
•
•
•
lnteroperability of health information technology
Transitions in care
Safety in ambulatory surgical centers
Measurement focused on episodes of care across and within settings
Outcome measures related to medical errors and complications
Greater focus on ambulatory, outpatient, and post-acute care
Assessment of workforce performance
Patient-reported outcomes
Pediatric: Performance Measures
•
•
•
•
•
•
•
•
Additional pediatric patient safety measures, such as measures related to dosing errors for
pediatric patients, pediatric diagnostic errors, and patient safety for outpatient pediatric
services
Measures pertaining to pediatric patients living with intellectual and/or developmental
disabilities, including measures for children with dual diagnoses of intellectual/developmental
disability and mental illness
Measures of coordination of care for children with chronic disease
Measures of quality for foster children, in particular, measures of foster care/ out-of-home
placement rates for substance-exposed newborns, and measures evaluating the time substanceexposed children spend in biologic-home settings versus foster care
Measures of how much time substance-exposed newborns spend in the acute care hospital,
NICU, rehabilitation, or children's specialty hospitals
Measures of quality evaluating abuse and mistreatment, including measures specifically focused
on children with special needs
Measures that capture social determinants of health
including food and housing
insecurity
Measures evaluating cost as it relates to children with special healthcare needs that are
technologically dependent
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•
•
•
•
Measures defining parental strengths and needs within a practice site
Measures to capture the identification of a team to work together to plan and test
improvements in eliciting parental strengths and needs within a practice site
Measures on integrating tools (e.g., process flows, prompts, and reminders) into practice flow to
support the engagement of parents
Clinic-/systems-level measures that offer more specificity about appropriate antibiotic
prophylaxis in children with sickle cell anemia
Person and Family Centered Care
•
•
•
•
•
•
•
•
•
Pediatric measures, especially for shared decision making
Measures derived from shorter versions of the CAHPS surveys
The next level of functional measures: measures not tied to traditional inpatient settings, and
that focus on functional restoration, becoming independent, and nonmedical outcomes (e.g.,
return to employment)
Setting-specific measures that ensure issues and outcomes specific to that site are measured,
for example, measures for ventilator care, which would only happen in Long Term Acute Care
(LTAC) Facilities and would not apply to Skilled Nursing Facilities (SNF) or Inpatient
Rehabilitation Facilities (IRFs)
Measures for partnerships between large health systems and community-based agencies, to
help health systems partner with high-quality community agencies
Additional measures of informed and shared decision making to ensure people are effective
advocates for their healthcare, including, how to choose and change a provider, how to use the
health care system to best advantage, how to use technology to benefit the patient, and how to
interpret quality data
Measures across the continuum of care, starting in primary care or emergency departments,
through the completion of all services for the patient
The medical neighborhood extending past the medical home and into other areas of the
community where care is received
Measures that specifically address eliciting and aligning patient goals with the plan of care
Renal
•
•
•
•
•
•
•
•
Patient-reported outcomes
Patient experience of care and engagement
Care for comorbid conditions
Palliative dialysis
Vascular Access
Young dialysis patients' preparedness for transition from pediatric facilities to adult facilities
Rehabilitation of people who are working age
Harmonization and improvement of measuring bloodstream infections across dialysis and other
facilities
Surgery
•
•
Outcome measures
Specialty areas that are still in early stages of quality measurement, including orthopedic
surgery, bariatric surgery, neurosurgery, obstetrics, gynecology, and smaller specialties (MAP
also identified gynecology and genitourinary measurement as gaps)
Pediatric (<18 years of age), including morbidity and mortality, either added to existing
measures or specific to pediatric populations
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•
•
•
•
•
•
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Adult and pediatric morbidity and mortality related to frequently performed cardiac procedures
beyond measures now available
Postsurgical functional status, including neurodevelopmental morbidity following pediatric and
congenital heart surgery
Surgery-related infections
Patient-centered approach to decision making including determination to forego treatment
Aggregated picture of episodes of care, including short· and long-term morbidity and patientreported outcomes, to include measures that cross organizational borders
Discharge coordination
Shared accountability
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Appendix 1: Medicare Measure Gaps Identified by NQF's Measure Applications
Partnership
During its 2016-2017 deliberations, MAP identified the following measure gaps-where high-value
measures are too few or nonexistent to drive improvement-for Medicare programs for hospitals and
hospital settings, post-acute care/long-term care settings, and clinicians.
Measure Gaps
Program
End-Stage Renal Disease Quality Incentive
Program (ESRD QIP)
•
•
•
•
PPS-Exempt Cancer Hospital Quality
Reporting (PCHQR) Program
0
•
•
Ambulatory Surgery Center Quality
Reporting (ASCQR) Program
•
•
•
Inpatient Psychiatric Facility Quality
Reporting Program (IPF QRP)
•
•
•
•
Assessment of quality of pediatric dialysis
Management of comorbid conditions (e.g., congestive heart failure,
diabetes, and hypertension)
Patient-reported outcomes such as functional status, quality of life,
and symptom management
Measures that assess safety events broadly (i.e. a measure of global
harm)
Quality of patients' informed consent process and assessment of
patient understanding of potential risks and benefits of treatment
Site infections
Complications
Patient and family engagement
Appropriate pre-operative testing
Medical comorbidities
Quality of psychiatric care provided in the emergency department
for patients not admitted to the hospital
Discharge planning
Condition-specific readmission measures
Access to inpatient psychiatric services, especially in rural areas
•
•
•
Use of evidence-based practices
Communication and care coordination
Hospital Inpatient Quality Reporting {IQR)
Program and Medicare and Medicaid EHR
Incentive Programs for Eligible Hospitals
and Critical Access Hospitals {CAHs)
•
"
Patient-reported outcomes
Dementia
Hospital Readmissions Reduction Program
{HRRP)
•
None discussed
Hospital Value-Based Purchasing Program
•
Reliable and actionable safety measures
•
Reliable and actionable safety measures
Hospital Outpatient Quality Reporting
(OQR) Program
•
(VBP)
Hospital-Acquired Condition Reduction
Program (HACRP)
I
Falls
Accurate diagnosis
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35419
Measure Gaps
Program
Merit-Based Incentive Payment System
(MIPS)
•
•
Outcome measures (e.g., episode-based as well as patient-reported
outcomes)
Improved process measures (e.g., composite measures, measures
tied to outcomes most important to patients)
I Quality
Care coordination {e.g., communication
Avoidable emergency department use
Person and family engagement
•
Experience of care measures related to patient and family
engagement
•
Inpatient Rehabilitation Facility Quality
Reporting Program (IRF QRP)
•
•
•
Medicare Shared Savings Program (MSSP)
l TCH-speclfi c CAH PS survey to assess experience of care
and timeliness of care)
•
Nutritional status measures
•
Transfer of information between clinicians
•
•
Experience of care
Efficacy of transfers from acute care hospitals to SNFs
•
Transfer of information between clinicians
Skilled Nursing Facility Value-Based
Purchasing Program {SNF VBP)
•
None discussed
Home Health Quality Reporting Program
(HH QRP)
•
Measures to drive adoption of congestive heart failure care
plans
Hospice Quality Reporting Program (HQRP
•
•
•
•
Medication management at the end of life
Provision of bereavement services
Patient care preferences
Symptom management for conditions other than cancer,
particularly dementia
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Appendix J: Medicaid Measure Gaps Identified by NQF's Medicaid Task Force and
the Dual Eligible Beneficiaries Workgroup
In 2017, NQF's Medicaid Task Forces and Dual Eligible Beneficiaries Workgroup identified the following
high-priority measure gaps for the Medicaid Adult and Child Core Sets of measures and the Dual Eligible
Beneficiaries Family of Measures.
High-Priority Measure Gap Areas
Medicaid Measure Set
•
Adult Core Set
•
•
•
•
•
Child Core Set
•
•
•
•
Dual Eligible Beneficiaries Family of
Measures
•
•
•
•
•
•
•
•
•
Behavioral health {integration and coordination with
primary and acute settings and outcomes)
Assessing and addressing social determinants of health
Maternal/reproductive health (e.g., Inter-conception care
and poor birth outcomes, access to obstetric care in the
rural community, and postpartum complications)
Long-term care-related supports and services (e.g., home
and community-based services, nursing home care)
New chronic opiate use
Substance abuse
Care coordination (e.g., care integration, social services
coordination, cross-sector measures, and care
coordination for conditions requiring community linkages)
Mental health
Overuse and medically unnecessary care as well as
underuse
Cost and resource use measures
Goal-directed, person-centered care planning and
implementation
Shared decision making
Systems to coordinate acute care, long-term services and
supports (LTSS), and nonmedical community resources
Beneficiary sense of control/autonomy/self-determination
Psychosocial needs
Community integration/inclusion and participation
Optimal functioning
Home and community-based services {HCBS)
Affordable and cost-effective care
National Quality Forum
1030 15th St NW, Suite 800
Washington, DC 20005
ISBN 978-1-68248-078-6
©2018 National Quality Forum
[FR Doc. 2018–15763 Filed 7–24–18; 8:45 am]
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]]>Agencies
[Federal Register Volume 83, Number 143 (Wednesday, July 25, 2018)]
[Notices]
[Pages 35318-35420]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-15763]
[[Page 35317]]
Vol. 83
Wednesday,
No. 143
July 25, 2018
Part II
Department of Health and Human Services
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Secretarial Review and Publication of the National Quality Forum 2017
Annual Report to Congress and the Secretary of the Department of Health
and Human Services Submitted by the Consensus-Based Entity Regarding
Performance Measurement; Notice
Federal Register / Vol. 83 , No. 143 / Wednesday, July 25, 2018 /
Notices
[[Page 35318]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[CMS-3348-N]
Secretarial Review and Publication of the National Quality Forum
2017 Annual Report to Congress and the Secretary of the Department of
Health and Human Services 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' (the Secretary) receipt and review of the
National Quality Forum 2017 Annual Report to Congress and the Secretary
submitted by the consensus-based entity under contract with the
Secretary in accordance with the Social Security Act. The Secretary has
reviewed and is publishing the report in the Federal Register together
with the Secretary's comments on the report not later than 6 months
after receiving the report in accordance with the Act.
FOR FURTHER INFORMATION CONTACT: Sophia Chan, (410) 786-5050.
SUPPLEMENTARY INFORMATION:
I. Background
The United States Department of Health and Human Services (HHS) has
long recognized that a high functioning health care system that
provides higher quality care requires accurate, valid, and reliable
measurement of quality and efficiency. The Medicare Improvements for
Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275) added
section 1890 of the Social Security Act (the Act), which requires the
Secretary of the Department of Health and Human Services (the
Secretary) to contract with the consensus-based entity (CBE) to perform
multiple duties designed to help improve performance measurement.
Section 3014 of the Patient Protection and Affordable Care Act (the
Affordable Care Act) (Pub. L. 111-148) expanded the duties of the CBE
to help in the identification of gaps in available measures and to
improve the selection of measures used in health care programs.
HHS awarded a competitive contract to the National Quality Forum
(NQF) in January 2009 to fulfill the requirements of section 1890 of
the Act. A second, multi-year contract was awarded to NQF after an open
competition in 2012. A third, multi-year contract was awarded again to
NQF after an open competition in 2017. Section 1890(b) of the Act
requires the following:
Priority Setting Process: Formulation of a National Strategy and
Priorities for Health Care Performance Measurement. The CBE must
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: (1) Address the
health care provided to patients with prevalent, high-cost chronic
diseases; (2) have the greatest potential for improving quality,
efficiency, and patient-centered health care; and (3) may be
implemented rapidly due to existing evidence, standards of care, or
other reasons. Additionally, the CBE must take into account measures
that: (1) May assist consumers and patients in making informed health
care decisions; (2) address health disparities across groups and areas;
and (3) address the continuum of care across multiple providers,
practitioners and settings.
Endorsement of Measures: The CBE must 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: The CBE must provide for the review and, as
appropriate, the endorsement of the episode grouper developed by the
Secretary on an expedited basis.
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; (2) 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 (3) 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 Act. The multi-
stakeholder groups provide input on quality and efficiency measures 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 must 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 an annual report. The report must describe:
The implementation of quality and efficiency measurement
initiatives and the coordination of such initiatives with quality and
efficiency initiatives implemented by other payers;
Recommendations on an integrated national strategy and
priorities for health care performance measurement;
Performance of the CBE's duties required under its
contract with the Secretary;
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;
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
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
[[Page 35319]]
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.
The statutory requirements for the CBE to annually report to
Congress and the Secretary of HHS also specify that the Secretary 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 6 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 2017 activities to the Secretary
on March 1, 2018. Comments from the Secretary on the report are
presented in section II of this notice, and the National Quality Forum
2017 Annual Report to Congress and the Secretary of the Department of
Health and Human Services is provided, as submitted to HHS, in the
addendum to this Federal Register notice in section III.
II. Secretarial Comments on the National Quality Forum 2017 Annual
Report to Congress and the Secretary of the Department of Health and
Human Services
Once again, we thank NQF and the many stakeholders who participate
in NQF projects for helping to advance the science and utility of
health care quality measurement. As part of their annual recurring work
to maintain a strong portfolio of endorsed measures for use across
varied settings of care and health conditions, NQF reports that in 2017
it updated its measure portfolio by reviewing and endorsing or re-
endorsing 120 measures and removing 109 measures. Endorsed measures are
developed and implemented with input from numerous stakeholders. These
measures undergo rigorous testing to ensure they are evidence-based,
reliable, and valid. Continuous refinement of the measures portfolio
through the measures maintenance process ensures that quality measures
remain aligned with current field practices and health care goals. HHS,
with the help of our partners, is committed to implementing measures
that provide value to payers and actionable information that can be
used to improve the health of patients.
NQF also undertook and continued a number of targeted projects
dealing with difficult quality measurement issues. In particular, NQF
has worked to help HHS address the unique challenges faced by rural
communities. Nearly one in five Americans reside in rural
communities.\1\ HHS recognizes the unique challenges facing rural
America, and with the support of partners like NQF, we are leveraging
quality measurement to improve access and quality for healthcare
providers serving rural patients. NQF recently completed several
projects that focused on rural health, including Performance
Measurement for Rural Low-Volume Providers \2\ and Creating a Framework
to Support Measure Development for Telehealth.\3\ Our reforms in the
area of rural health are part of our overall strategy to update our
programs and improve access to high quality services.
---------------------------------------------------------------------------
\1\ U.S. Census Bureau, 2010 Census, Table GCTPH1.
\2\ https://www.qualityforum.org/Publications/2015/09/Rural_Health_Final_Report.aspx.
\3\ https://www.qualityforum.org/Publications/2017/08/Creating_a_Framework_to_Support_Measure_Development_for_Telehealth.aspx.
---------------------------------------------------------------------------
In 2017, recognizing the need to strengthen representation of rural
stakeholders in the pre-rulemaking process, HHS tasked NQF to establish
a Measures Application Partnership (MAP) Rural Health Workgroup. The
membership of the MAP Rural Health Workgroup, comprised of 18
organizational members, seven subject matter experts, and three federal
liaisons, which reflects the diversity of rural providers and residents
and allows for input from those most affected and most knowledgeable
about rural measurement challenges and potential solutions. The MAP
Rural Health Workgroup represents a continuation of HHS' effort to
address rural health. With valuable input from our partners and
stakeholders, HHS can continue to improve health care in rural America.
The MAP Rural Health Workgroup has focused on identifying a core
set of the best available, ``rural-relevant'' measures to address the
needs of the rural population. The MAP Rural Health Workgroup is also
working to identify measurement gaps with respect to rural communities
and provide recommendations regarding alignment and coordination of
measurement efforts across both public and private programs, care
settings, specialties, and sectors (both public and private).
Additionally, the MAP Rural Health Workgroup provides guidance for the
MAP to ensure that measures under consideration address rural provider
and resident needs and challenges. The MAP Rural Health Workgroup's
recommendations are also helping to address specific barriers to
quality reporting faced by rural clinicians. Furthermore, the MAP Rural
Health Workgroup has provided a space for rural clinicians to broadly
share their valuable input. Rural physicians contribute unique and
valuable perspectives critical to addressing national challenges, such
as the opioid epidemic. However, rural physicians are often isolated
from national discussions on relevant measures that could identify
areas of need and gauge prevalence. Highlighting the valuable input
from rural clinicians opens collaboration opportunities between rural
providers and providers in other settings as HHS works to integrate new
measures concerning the prevention and treatment of opioid and
substance use disorders.
Addressing the needs of rural health communities is just one of
many areas in which NQF partners with HHS in enhancing and protecting
the health and well-being of all Americans. HHS greatly appreciates the
ability to collaborate with diverse stakeholders and partners to help
develop the strongest possible approaches to quality measurement as a
key component to health care delivery system reform.
III. Collection of Information Requirements
This document does not impose information collection requirements,
that is, reporting, recordkeeping, or third-party disclosure
requirements. Consequently, there is no need for review by the Office
of Management and Budget under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq.).
IV. Addendum
In this Addendum, we are publishing the NQF Report on 2017
Activities to Congress and the Secretary of the Department of Health
and Human Services, as submitted to HHS.
Dated: June 21, 2018.
Alex M. Azar II,
Secretary, Department of Health and Human Services.
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[FR Doc. 2018-15763 Filed 7-24-18; 8:45 am]
BILLING CODE 4120-01-C
