Health Care Quality: HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures
Fast Facts
Hurdles to measuring and rewarding quality health care
Medicare and other health care payers are increasingly examining the quality of the services people receive—and adjusting payments accordingly. But payers don’t agree on which quality measures to track, making it difficult to improve the quality of care and burdening doctors and other providers with reporting different data to different payers. While the Department of Health and Human Services is working to better align its health care quality measures across programs and private payers, we recommend that it set key priorities for these efforts and develop more meaningful measures.
General Overview of a Health Quality Measure: Blood Pressure Control
Illustration of how to calculate physician performance to measure blood pressure control
Highlights
What GAO Found
While the full extent of misalignment among health care quality measures is unknown, it can have adverse effects on providers and efforts to improve quality of care. Misalignment occurs when health care payers require providers to report on measures that focus on different quality issues or define the measures using different specifications. GAO identified three studies that provided some information on the extent of misalignment. For the most part, these studies examined the number of measures that were used in common, among a narrow selection of public and private payers, and found that with few exceptions, only a small proportion of measures were commonly used by these payers. The Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) agrees that misalignment exists, and some experts note that it adds to providers' administrative burden and often results in quality information that is not comparable.
GAO's interviews with HHS officials and experts indicate that three interrelated factors drive misalignment of health care quality measures, as described in the table.
Factors Driving Misalignment of Health Care Quality Measures
|
Factor |
Description |
|
Dispersed decision-making |
Among public and private payers and other stakeholders, each entity independently decides which quality measures it will use and which specifications should apply to those measures. |
|
Variation in data collection and reporting systems |
Payers may choose different measures, modify existing measures, or leave details about measure specifications up to providers in order to accommodate differences in data that providers collect and the systems they use to collect these data. |
|
Few meaningful measures |
Although hundreds of quality measures have been developed, relatively few are measures that payers, providers, and other stakeholders agree to adopt, because few are viewed as leading to meaningful improvements in quality. |
Source: GAO interviews with Department of Health and Human Services officials and experts. | GAO-17-5
HHS has various ongoing efforts that address different aspects of misalignment of quality measures and the three factors that drive it. For example, HHS has begun to address dispersed decision-making by negotiating with private payers to adopt a core set of measures. To address variation in data systems, HHS is taking steps to develop electronic quality measures—those that allow providers to report data electronically—and standardize the data collected under these measures. CMS has also taken steps to address the paucity of meaningful measures through efforts to develop new measures that focus on key quality concerns. However, HHS has not prioritized development of electronic quality measures specifically for the core measures CMS negotiated with private payers, which could delay the implementation of this alignment effort. Further, CMS has not comprehensively planned how to target the development of new, more meaningful measures that address misalignment, and it has not set timelines and methods to track its progress. Federal internal control standards and leading principles for planning call for agencies to prioritize their efforts and assess their progress in achieving their objectives. Without comprehensive planning, CMS cannot ensure that it will achieve its objective of reducing misalignment.
Why GAO Did This Study
Both the federal government and private payers, such as health plans, increasingly use quality measures to encourage providers to improve health care quality. In addition to its ongoing programs that use quality measures to assess provider performance, HHS has proposed to begin implementing the CMS Quality Payment Program, in January 2017. However, if measures are misaligned across these programs, the misalignment could create administrative burden for providers.
The Medicare Access and CHIP Reauthorization Act of 2015 includes a provision for GAO to examine the use of quality measures across HHS programs and private payers, with a focus on reducing burden. In this report, GAO examined (1) what is known about the extent and effects, if any, of quality measure misalignment; (2) key factors that can contribute to misalignment; and (3) HHS's efforts to address any misalignment. GAO conducted a literature review to identify related studies; reviewed HHS documents; and interviewed HHS officials and experts from 16 organizations that represent a range of perspectives, including providers and payers.
Recommendations
GAO recommends that HHS (1) prioritize its development of electronic quality measures and related data elements for the core measures it and private payers have agreed to use, and (2) comprehensively plan, including setting timelines for, its efforts to develop more meaningful quality measures. HHS concurred with the recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | To make it more likely that HHS will achieve its goals to reduce quality measure misalignment and associated provider burden, the Secretary of HHS should direct CMS and the Office of the National Coordinator for Health Information Technology to prioritize their development of electronic quality measures and associated standardized data elements on the specific quality measures needed for the core measure sets that CMS and private payers have agreed to use. |
HHS has prioritized the development of electronic quality measures and associated standardized data elements on the specific quality measures needed for the core measure sets developed by the Core Quality Measures Collaborative (CQMC). In November 2021, CMS told us they have worked with the National Quality Forum (NQF) and the health insurance plan association AHIP to prioritize the use of electronic quality measures in the core sets established in a contract task order. The goal of these measure sets is to include a greater percentage of electronic measures in the core sets as they become available, according to officials. CMS officials reported that at CQMC's inception, 24 percent of core measures were either an electronic quality measure or had electronic reporting options available. In 2020, that percentage increased to 27 percent. In September 2021, CMS published a guide for stakeholders on how to effectively implement core measure sets that includes information on the importance of promoting alignment by using the most recent versions of the defined measure specifications when implementing core measure sets. Additionally, CMS told us the CQMC is also working to provide examples and a process for transitioning the CQMC's core measure sets to electronic quality measures. ONC has also taken steps to facilitate the use of electronic quality measures, such as through its Electronic Clinical Quality Improvement Resource Center. ONC also maintains a public repository of measures that provides information on the data elements associated with the electronic quality measures used in CMS's quality reporting and incentive programs. Publishing this repository allows measure developers to identify the data elements used by CMS for its programs so that the developers can incorporate the data elements into their electronic health records, further standardizing data elements used for electronic quality measures. These actions to prioritize the development of electronic quality measures and associated standardized data elements for the core measure sets will help HHS to achieve its goals to reduce quality measure misalignment and associated provider burden.
|
| Department of Health and Human Services | To make it more likely that HHS will achieve its goals to reduce quality measure misalignment and associated provider burden, the Secretary of HHS should direct CMS to comprehensively plan, including setting timelines, for how to target its development of new, more meaningful quality measures on those that will promote greater alignment, especially measures to strengthen the core measure sets that CMS and private payers have agreed to use. |
CMS comprehensively planned for how to target its development of new, more meaningful quality measures on those that will promote greater alignment. In September 2021, CMS reported they have a contract in place with the National Quality Forum that includes a task order aimed at achieving widespread adoption of the Core Quality Measures Collaborative (CQMC) measure sets, among other things. The task order included key tasks and deadlines for several activities, such as creating new core measure sets. In addition, CMS finalized a CQMC Implementation Guide in September 2021. This implementation guide includes information on elements of success for value-based payment implementation, including measure alignment. In particular, the implementation plan emphasizes that core measures should be prioritized for implementation in new or existing programs. CMS's comprehensive planning through the task order and implementation plan will help the agency to target the development of new measures that promote greater alignment, particularly those for the core measure sets.
|