CMS Quality Measures Reveal Progress Toward Goals

CMS’ 2015 National Impact Assessment of Quality Measures Report reveals progress toward the three aims of better care, smarter spending, and healthier people. The report examines the effectiveness of quality measurements used by CMS, summarizes key findings, and recommends next steps for even greater efficacy. The next Impact Report will be released in 2018, and current projections indicate that report will include almost twice as many quality measures as the current report as the program develops.

Impact Report

The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) requires CMS to issue these reports at least once every three years. This mandate stemmed from the gap between high quality care and care received by patients and the desire to improve care received. The ACA not only mandated the assessment of the quality impact of endorsed measures, but also required the development of the National Quality Strategy (NQS). CMS then aligned its goals with those in the NQS and it publicly reports the quality measures. This report includes trend analysis for data collected during three consecutive years between 2006 and 2012, and descriptive analysis for data available for fewer than three consecutive years, but in use through December 2013.

Notable Findings

The study found that current CMS quality measures support the National Quality Strategy (NQS) and CMS Quality Strategy, however, significant gaps remain across all measure domains. The Affordable Care and Care Coordination domains are the most underrepresented. The CMS measures do reach a significant majority of the top 20 high-impact Medicare conditions experienced by beneficiaries. Further, improvement was shown in 95 percent of 119 publicly reported measure rates under these quality measures.

Patients affected by the use of quality measures were found to include more than just the Medicare population, as 40 percent of the Medicaid population and 30 percent of individuals covered by other sources were also affected. No patterns that systematically exclude specific populations were found in the study.

Process measures, which address clinical guidelines for patient care, were likely to be high performing. Outcome rates for providers are found to improve more slowly than process measures. For approximately 35 percent of the measures, performance was so high that additional improvement will have little effect on patient outcomes. Although race and ethnicity disparities were much less pronounced in 2012 than 2006, these disparities persist and require additional attention.

CMS’ proposed action includes promoting transparency and more closely monitoring measure rates, comparing them within groups of providers treating in areas with minority and underserved populations. It also plans to further research what degree of alignment in quality measures between state and federal programs would benefit patients and providers.

Looking Ahead

CMS is already focusing on certain points for the 2018 Impact Report. Several recently introduced programs did not have enough data available for trend analysis for the current report, but will be heavily analyzed in the future. Patient-level data is a primary concern. A national provider survey will be conducted on the impact of quality measures at the provider level.

Learning and Action Network for Value-Based Payment Systems Now Open

CMS is forming a Health Care Payment Learning and Action Network (LAN) to allow discussion and the formulation of public-private partnerships in furtherance of HHS’ goal of moving the Medicare program to value-based and alternative payment models. Secretary Burwell announced this initiative in January, which seeks to shift the focus of the health care system from volume to quality of care (see Goals and timeline set for achieving value-based Medicare reimbursement, January 26, 2015). The LAN will allow all concerned parties to discuss the transition toward these alternative models.

Roles

An independent contractor will operate the LAN, acting as convener and facilitator. The contractor will organize meetings and release information to participants as well as lead learning sessions. Workgroups will be created for the purpose of cataloguing best practices and implementation guides for payment reform. The contractor will also provide logistical support and unite technical experts from all levels of participant involvement.

A Guiding Committee will prioritize the discussion topics and issue recommendations to the contractor. The Guiding Committee will be formed from LAN participants. The committee and contractor will work together to create workgroups that will address specific areas. The materials generated from these workgroups will be released through webinars and live meetings.

Activities

The LAN will serve several functions. It will collaborate with payers, providers, employers, purchasers, states, consumer groups, and individuals to share approaches and generate evidence and best practices. It will decide on best approaches to issues such as financial models, assessment measurements, risk adjustment, and other topics raised by participants. It will create implementation guides and identify how to best report on new payment models.

Participation

Participants should contribute to workgroups and strive to share and receive information. Stakeholders will be expected to work with participants to support model goals that meet or exceed Medicare’s goal of 30 percent alternative payment model penetration by 2016 and 50 percent by 2018. Within the first six months, stakeholders will need to set organization-specific goals and report progress toward the national goal. LAN participation requires no fees, but organizations will not receiving funding from HHS or CMS for participation. Registration is now open.

Outpatient Departments Care for Sicker & Poorer Patients than Physician Offices

Patients treated for nonemergency services in hospital outpatient departments (HOPDs) are sicker and more likely to be from low income areas compared to patients receiving the same care in physician offices, according to a study prepared for the American Hospital Association by KNG Health Consulting, LLC. The study examined the differences in the two types of care facilities so that Medicare payment reforms can be more accurately developed in light of the different kinds of care challenges that HOPDs and physician offices face.

Study

The study was designed to evaluate the differences between the patients served and the care provided for nonemergency services in HOPDs and physician offices because of proposed changes to Medicare payments that would cap payments to HOPDs for nonemergency services at the rate paid to physicians. The study specifically evaluated differences in patient populations between the two different types of facilities and the variance in the facilities’ care. The study evaluated differences in reasons for visits and the services, treatments, and medications ordered or provided. To conduct the study, KNG looked at the National Ambulatory Medical Care Survey (NAMCS) from 2008 to 2010 and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from the same date range. The data analysis also included an evaluation of the 2012 Standard Analytical File of a 5 percent sample of Medicare beneficiaries.

Findings

Among the studies key findings were that patients in HOPDs were: 1.7 times more likely to be Black or Hispanic; 2.5 times more likely to rely on Medicaid, self-pay or charity care; 1.7 times more likely to live in a low-income area; 1.5 times more likely to live in a low-education areas; more likely to be burdened by more chronic conditions; and more likely to be hospitalized prior to receiving ambulatory care. Additionally, in terms of the differences in the care itself, when compared to physician offices, nonemergency care in HOPDs was: more likely to be delivered to a new patient, 1.2 times more likely to be for the receipt of treatment, more likely to include the ordering of additional treatment or services, and more likely to include the care of a nurse.

Room for Improvement in Hospital Maternity Care

Rates of early induction of labor have declined in U.S. acute care and pediatric hospitals, but rates of episiotomies  remain unacceptably high in many hospitals, according to a 2014 survey released by the Leapfrog Group and developed by Castlight Health.  The survey results also reflected little change in the number of hospitals meeting Leapfrog’s standards for high-risk deliveries since 2013.  The American Congress of Obstetricians and Gynecologists (ACOG) has long advised limiting both elective inductions prior to 39 weeks’ gestation and the use of episiotomies.  Leapfrog has made suggestions for improvement to hospitals, and existing CMS programs seem to support the advice as far  as inductions are concerned.

Elective Inductions

Definitions of “full term” range from 39 weeks’ gestation to 40 weeks and six days.  However, according to Leapfrog, rates of elective inductions, those with no medical basis, prior to 39 weeks, increased from 9.5 percent in 1990 to 32.9 percent in 2009.  Providers and patients may choose early inductions for nonmedical reasons le convenience, perceived liability, or relief of pregnancy symptoms.  However, infants born at 36 to 38 weeks are more likely than full-term infants to have lung problems and other medical issues, often requiring treatment in the neonatal intensive care unit (NICU).  Long-term effects on academic achievement resulting from preterm birth may also be seen.  Mothers whose labor is induced are more likely to undergo cesarean sections (C-sections) than women who are not induced, and they may be at higher risk of other postpartum complications.  In addition, Leapfrog cited a study finding that the early deliveries cost up to 17.4 percent more than full term early deliveries.  If early term delivery were reduced to 1.7 percent, the report suggests, the U.S. could  save $1 billion annually, much of which results from a reduction in days spent in the NICU.

Leapfrog has defined its standard for early elective deliveries as a rate of scheduled C-sections or inductions before 39 weeks no greater than 5 percent.  In 2010, only 30 percent of hospitals responding to the survey met the standard.  The rate increased  over time, to 71 percent in 2013 and 78 percent in 2014.  The numbers are positive; however, significant variation exists among hospitals, with 17 hospitals reporting early elective delivery rates of 30 percent or more.

Recognizing the dangers of elective inductions, and perhaps the financial costs associated with them, CMS launched  the Strong Start for Mothers and Newborns initiative in  2012, which promotes awareness, spreads best practices, and promotes transparency.  In an August 2012 final rule, CMS added a measure to the Inpatient Quality Reporting (IQR) Program that is effective for fiscal year (FY) 2015: Elective delivery prior to 39 completed weeks of gestation, which will link quality of care with payment.  In December 2013, the agency updated its Hospital Compare website to include voluntary reports of the measure. CMS also created the Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid and CHIP to explore opportunities that could not only result in better care and outcomes, but reduce the cost of care for mothers and infants enrolled in Medicaid and the Children’s Health Insurance Program. The recommendations, in part, led to the creation of the Maternal and Infant Health Initiative.

Episiotomies

Episiotomies are incisions made in the perineum–the area between the vagina and the anus–during childbirth.  The procedure was formerly a routine part of childbirth intended to prevent worse tears of the perineum.  However, they have been linked to worse tears, bladder and fecal incontinence, pelvic floor defects, and painful recoveries.  The Mayo Clinic notes that episiotomies may be warranted in certain cases, such as when a physician anticipates “extensive vaginal tearing,” the baby is an abnormal position, or the baby needs to be delivered quickly. Leapfrog’s standard rate for episiotomies is less than or equal to 12 percent. Sixty-five percent of reporting hospitals achieved the standard in 2014 and the national average was 11.3 percent, down less than two percentage points from 2012. However, dramatic variations were seen.  Twenty-five hospitals reported rates of less than or equal to 1 percent, but 12 reported rates of 40 percent or greater. To further encourage a decrease in episiotomies, Leapfrog plans to lower its standard from less than or equal to 12 percent to less than or equal to 5 percent; only 27 percent of hospitals reporting in the 2014 survey would meet that standard.

High-Risk Deliveries

Infants who weigh less than 3 pounds, 4.91 ounces should be cared for in a NICU.  They have a higher likelihood of survival and better prognoses when they are born at hospitals with experienced, on-site NICUs. Leapfrog deems hospitals to meet standards for high-risk deliveries if they ensure that at least 80 percent of mothers receive antenatal steroids prior to delivery, which can reduce the incidence and severity of respiratory distress syndrome (RDS) in infants, as other well as other issues, including mortality; and either (1) deliver at least 50 “very low” birth weight babies each year or (2) maintain a lower than average morbidity/mortality rate for very low birth weight babies. In 2014, 24.4 percent of reporting hospitals met this standard, which is only an increase of 0.4 percent since 2013, although some hospitals are making “substantial progress.”  Hospitals in 24 states reported on this standard.  Strikingly, no hospitals in Georgia, Missouri, or South Carolina met Leapfrog’s high-risk delivery standard; only 4 percent of hospitals  reporting from New York met the standard.

Looking Forward

While the survey results reflect improvement, there is clearly room for improvement.  In addition, variations among suggest that standards are not being consistently achieved across hospitals.  Leapfrog will continue to assess hospitals’ compliance with its maternity standards and report again in 2016.