Tuesday, 23 February 2016 16:30

Core Measures for All Plans – A Strong Reminder that Reimbursement Reform is at a Tipping Point

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Earlier this month, a joint health plan consortium released a set of quality measures intended to serve all payors. Covering primary care and certain high-expense specialties, the measures are intended to “reduce, refine, and relate” measures for a consistent and unified approach to promoting affordable quality healthcare. Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS) stated that “this agreement today will reduce unnecessary burden for physicians and accelerate the country's movement to better quality.”

The Core Quality Measures Collaborative includes health plan representatives for an estimated 70 percent of covered patients across the U.S. Payor representatives on the Collaborative include CMS, America’s Health Insurance Plans, Aetna, Anthem, the Blue Care Network, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield Association, Cambia Health Solutions, Cigna, Group Health Cooperative, Harvard Pilgrim Health Care, HealthPartners, Heath Care Service Corporation, Highmark, Humana, Kaiser Permanente, The AmeriHealth Caritas Family of Companies, and UnitedHealth Group.

The first release of the “Consensus Core Set” groups measures that have been publicly endorsed by the National Quality Foundation as quality measures and NCQA health plan HEDIS measures. For example, in the primary care core set, titled “ACO and PCMH/Primary Care Measures,” the Collaborative endorsed the forthcoming 2016 HEDIS measure for controlling high blood pressure rather than NQF 0018, noting that the NQF measure’s recommended systolic blood pressure target is not in line with the 2014 guidelines (140 mmHg). Instead, the NQF measure aligns to the outdated 2004 Joint National Committee hypertension guidelines. This divergence of measure recognition underscores the lag in the measure development and endorsement process and highlights a gap in the federal quality initiatives. Since NCQA is the measure steward for both the NQF and HEDIS measures, the hope is that the 2017 NQF measures reflect the 2014 guidelines.

For leaders curious about how they can capture reports that align to these measures with ease, the NQF measure is used for both the Medicare Physician Quality Reporting System and the certified electronic medical record technology meaningful use attestation. Thus, inconsistencies in evidence-based medicine and availability of updated guidelines continue to represent a gap in the national construct of quality measurement. It’s one thing to endorse what should be captured; it’s another to require vendors to incorporate the appropriate measures into technology available at the point of care. And without this mandate, it simply won’t happen.

The February 2016 Core Measure Set Release included:

  • ACO and PCMH/Primary Care Measures
  • Cardiovascular Measures
  • Gastroenterology Measures
  • HIV/Hepatitis C Core Measures
  • Medical Oncology Measures
  • OB/GYN Measures
  • Orthopedic Measures

The day after the release of the Core Measure Sets, CMS closed the extended comment period on their request for information on the certification frequency and requirements of clinical quality measures for the meaningful use program. The agency received 150 comments from a broad group of individuals and organizations representing physicians, hospitals, consultants, and vendors. However, few comments provided guidance on how to integrate measures when new evidence-based medicine conflicts with endorsed measures. However, numerous commenters requested over a year to implement changes in quality measures to allow vendors and on-the-ground providers to respond with adequate training and technology.

The Core Measure Sets include one important guidepost. At the end of each document, the Collaborative included “future areas for measure development.” Here, industry geeks can find exciting true quality measurement metrics with outcome focus and items of interest for employers. In the orthopedic measures, the Collaborative listed emergency department visits, which good orthopedic care and coordination with urgent care should divert away from the ED. Likewise, the “health-related quality of life” measures get to the patient-reported outcomes reflecting adequate primary care coordination.

Overall, this development is exciting. To share industry consensus regarding the measurement of quality will be a fascinating endeavor. The next step over the next three years will be integrating these measures into the payment methodology for public and private entities. This early menu is a starting point where some larger healthcare entities can begin to identify synergistic measures that have been shown to bend the cost curve. For smaller organizations, this publication should kick-start the budget review process for strong investment in technology to capture quality data and provide analytics to identify pockets of shared savings.

About the Author

Jennifer is the Founder and CEO of SCG Health.  Previously Jennifer was the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payer operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare.  Prior to this, Jennifer served as the External Relations Liaison for the Washington, DC-based Government Affairs Department of the Medical Group Management Association (MGMA). As the External Relations Liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the Government Affairs Representative for the Eastern & Southern Sections. She began her work with MGMA in August of 2001.  She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics In Context.

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Last modified on Tuesday, 23 February 2016 16:40

Jennifer is the Founder and CEO of SCG Health. Previously Jennifer was the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. From 2007 to April 2011, she established and led the Provider Communications & Advocacy unit. This enterprise asset reviewed and approved communications for the commercial, Medicare and Medicaid participating providers in the UnitedHealthcare network. She also solicited direct feedback on how to improve payer operations from the physician and hospital community, which resulted in higher provider satisfaction rates with the national insurance company during her tenure at UnitedHealthcare. Prior to this, Jennifer served as the External Relations Liaison for the Washington, DC-based Government Affairs Department of the Medical Group Management Association (MGMA). As the External Relations Liaison, Jennifer coordinated MGMA advocacy efforts with other specialties and medical organizations. She also was the Government Affairs Representative for the Eastern & Southern Sections. She began her work with MGMA in August of 2001. She serves on the board of the Maryland Medical Group Management Association and is a clinical adviser for Informatics In Context.