This document summarizes a presentation given by Helen Burstin on quality measurement, past and future. Some key points include: - NQF leads consensus-based standard setting to improve healthcare quality through measurement. It convenes stakeholders to reach agreement on complex issues. - Recent legislation has increasingly tied payment to quality measurement to encourage value-based care. The MACRA law establishes two paths for physicians, one based on quality metrics and one through alternative payment models. - Measurement is evolving to better assess outcomes, reduce disparities, and capture value by linking cost and quality. Challenges include measurement gaps, unintended consequences, risk adjustment, and advancing electronic capture of data. - There is a need

1. Quality Measurement:
Past and Future
Helen Burstin, MD, MPH, FACP
Chief Scientific Officer, NQF
SAGES Meeting
May 15, 2015

2. NQF: What We Do
Improve health and healthcare quality through measurement
• Gold standard for quality measures – consensus-based
standard setting organization
• An essential forum - >400 members and >800 volunteer
leaders across multiple stakeholders
• Quality leadership – convenes private and public sectors
to reach consensus on healthcare’s complex and
controversial issues (e.g., SES risk adjustment, linking cost
and quality)
2

3. The National Quality Strategy
3

4. HHS Value Based Payment Goals
4

5. Legislative History of Quality
5
 Quality measurement embraced by both sides of the aisle
▫ 2008: Medicare Improvements for Patients and
Providers Act
▫ 2010: Patient Protection and Affordable Care Act (ACA)
 Recent extensions:
▫ 2013: American Taxpayer Relief Act - QCDR
▫ 2014: Protecting Access to Medicare Act – Imaging
▫ 2015: Medicare Access and CHIP Reauthorization Act –
“SGR Fix”

6. SGR Fix (MACRA)
 A leap on the path toward paying physicians for value not
volume – it is a journey
 Aligns three physician-level programs and eliminates yearly
uncertainty (“the cliff”) by stabilizing payments
 Longer term approach (2020 – ongoing)
▫ First 5 years - two paths available to increase pay
» Reward/penalize based on the Merit-Based Incentive
Payment System (MIPS)
» Participate in a qualified Alternative Payment Model
(APM)
6

7. Moving Toward Efficiency & Value
Measurement
7

8. Tensions in Measurement
8

9. IOM Report – Vital Signs
9
▫ Identify a set of standardized measures required at
national, state, local, and institutional levels.
» Limited set of measures:
• Outcomes oriented
• Reflective of system performance
• Meaningful
• Utility at multiple levels of the health care system.
▫ Recognized that any particular measure will vary in its
utility at different levels (e.g., community, practice)

10. US Societal Vital Signs
10
 Life expectancy
 Well being
 Overweight and obesity
 Addiction behavior
 Unintended pregnancy
 Healthy communities
 Preventive services
 Care access
 Patient safety
 Evidence based care
 Care match with patient
goals
 Personal spending burden

11. Measurement in Evolution
 Measures that reflect higher performance (e.g., optimal
performance)
 Focus on outcome measures that are more patient
centered (e.g., Patient Reported Outcomes)
 Harmonize and align measures to reduce burden and
accelerate improvement
 Address disparities in all we do
 Build on cost and quality measurement to assess value,
including appropriateness and overuse
 Transition to electronic platforms and eMeasures
 Emerging focus on population health
11

12. The State of eMeasurement
 Difficult to identify structured fields needed for quality measurement
 Lack of comparability across EHR systems
 Data elements needed for advanced measures may not be feasible
to capture in EHRs
 Tracking quality and value across settings and populations limited by
lack of interoperability
 Limited ability to take advantage of clinical data in EHRs, registries,
and patient portals and other sources (e.g., claims, demographics)
 Complexity of testing across multiple EHRs; limited test beds
 Limited standardization of key building blocks of new eMeasure
development (e.g., data elements, value sets)
12

13. Challenges in Measurement
 Persistent measurement gaps -- especially those meaningful to
surgeons and patients
 Unintended consequences of measurement, including burden
 Appropriate level of analysis – surgeon v. institution
 Alignment and harmonization of measures
 Complex measurement science issues –
▫ SES /Risk Adjustment
▫ Linking cost and quality
▫ Attribution
▫ Comparability
▫ Measurement for intended use
13

14. Views on Adjustment for SES and Other
Demographic Factors
14
OPPOSE
- Some providers may deliver worse quality care to
disadvantaged patients
- Adjustment could make meaningful differences in quality
disappear
- Worse outcomes could be expected
No expectation to improve
Implies or sets a different standard
- Lack of adequate data for SES adjustment
- Prefer payment approach to help safety net
SUPPORT
- Risk adjustment allows for comparative performance
- A performance score alone (whether or not adjusted for SES factors)
cannot identify disparities.
- Hospitals caring for the disadvantaged are already being penalized.
- No evidence that disparities would be reduced through further
negative financial incentives.
- Lack of adjustment would continue to create a disincentive to care
for the poor.

15. NQF Policy Change: Trial Period
 The Panel recommended, and the NQF Board approved, a
two-year trial period prior to a permanent change in NQF
policy.
 Under the new policy, adjustment of measures for SES factors
is no longer prohibited.
 During the trial period, if SES adjustment is determined to be
appropriate for a given measure, NQF will endorse one
measure with specifications to compute:
▫ SES-adjusted measure
▫ Non-SES version of the measure (clinically-adjusted only)
to allow for stratification of the measure
15

16.  IOM report, Best Care at
Lower Cost: The Path to
Continuously Learning
Health Care in America, cites
feedback loops as essential
for continuous learning and
system improvement
 Continuously learning
system uses information to
change and improve its
actions and outputs over
time
Need for Ongoing Measure Feedback
16

17. More Collaboration Needed in Measurement
Prioritize
Measure Gaps
Catalyze Gap
Filling
Endorse
Measures
Select
Measures
Promote
alignment
Evaluate
impact

18. Vision for Quality Measurement
 Align measures to reduce burden and accelerate
improvement; end duplication within and across settings
and providers
▫ Reduce cacophony and increase relevance
 Identify measures that are actionable, meaningful, and lead
to better health outcomes
 Advance measurement to accurately and reliably assess
value
 Achieve consistency and rigor in consumer information
▫ Hospital Rankings (Health Affairs, March 2, 2015)
18

19. Discussion
Helen Burstin, MD, MPH, FACP
hburstin@qualityforum.org
19