The Covid-19 pandemic is the nudge the Medicare and Medicaid agency needed to rethink what quality measures it asks providers to report, health policy experts said.
The industry is questioning the utility of having so many quality measures at a moment when doctors and resources are stretched thin. Providers said the measures can be easy to game and arduous to report, and they’re expensive for themselves and the government. Studies have shown some measures may not lead to higher quality care.
The Centers for Medicare & Medicaid Services spent more than $1.3 billion on quality measure development between 2008 and 2018, according to a 2020 study published in the JAMA Network Open. The measures translate to more than $15.4 billion in spending for physicians, with providers in common specialties spending more than 15 hours per physician per week on quality reporting, according to a 2016 study published by Health Affairs.
“There’s an emerging medical term called ‘pajama time,’” said Richard Dutton, chief quality officer for U.S. Anesthesia Partners. “You take care of patients all day, but then, when you go home, you have to spend a couple of hours in front of the computer in your pajamas doing all the documentation,” Dutton said. Reporting these measures is “very redundant, very bureaucratic, and not really helping patient care.”
Providers paid by the CMS are incentivized to report certain metrics about the quality of care they deliver, which determines whether they gain or lose funding. The 729 measures that providers must report back to the agency as part of quality programs reflect the health-care industry’s shifting focus from payment for quantity of services to value-based payment for quality of services.
“Now we have the right constellation of historical moment and circumstance” to allow the CMS to engage in quality measurement reform, said Kedar Mate, president and CEO of the Institute for Healthcare Improvement.
“We don’t have a whole lot of time, or energy, or money to waste,” Mate said, so the CMS needs to focus on “capturing measures that really matter to people.”
More useful measures tend focus on patient outcomes, Mate said, such as the percentage of patients who die 30 days after being admitted for a heart attack. Measures reported by patients are also valuable—for example, a patient’s functional status after a hip replacement. By contrast, process-oriented measures, such as whether a patient was discharged on a cholesterol-lowering drug, are less helpful, Mate said.
The CMS is developing an initiative that builds on previous efforts to curb the number of measures providers must report. The initiative will focus on prioritizing patient outcomes and making measures totally digital by 2025, according to the agency.
“CMS continues to evaluate its quality measurement strategy incorporating lessons learned from the COVID-19 pandemic,” a CMS spokesperson said.
Measures to Improve
Improving outcomes for patients lies at the heart of any quality measure, said Tricia Elliott, senior managing director of National Quality Forum, an organization that evaluates and endorses some CMS quality measures.
Such measures can be reported to the public, allowing patients, caregivers, and even clinicians to make better-informed decisions, said Laura Smith, senior research public health analyst for the Quality Measurement and Health Policy Program at research firm RTI International.
About 97% of eligible doctors participated in the CMS’ Merit-Based Incentive Payment System in 2019, according to a 2020 report. The MIPS program, one of the CMS’ central quality payment programs, rewards doctors who provide high-quality care and penalizes those who don’t. Participation in the program has beaten the CMS’ expectations, leading to modest payouts for doctors.
Measuring quality of care is in line with the Biden administration’s priority to close health equity gaps. It also infuses clinicians and health system leaders with “more vigor” to try and tackle injustices in the health-care system, Mate said.
The CMS recently solicited feedback on several quality measures that would close equity gaps related to race, ethnicity, and other factors. “In general, health-care facilities are very supportive of measures and programs to advance equity,” a CMS spokesperson said.
Providers said that while some measures inform their practice and leave patients better off, others are an exercise in box-checking.
A recent study, also published in the Journal of the American Medical Association, found that physician MIPS scores using self-selected quality measures are “at best, only weakly associated with hospital performance.”
Tying financial incentives to quality improvement can inspire gamesmanship. “People are going to choose the measures that they’re already doing well in to get credit, even though what they really should do is focus on what they’re not doing well at,” said Kerin Adelson, chief quality officer and deputy chief medical officer at the Yale Cancer Center and Smilow Cancer Hospital.
Some measures get topped out, with median performances at over 95%, the CMS said. “If everybody’s above average, it’s impossible to use the measure to sort out good doctors and bad doctors,” Dutton said.
Giving providers a “supportive learning environment” before incentivizing them with payment could promote better outcomes. Most clinicians are “driven largely by intrinsic desire to get better,” Mate said.
The CMS regularly solicits feedback from stakeholders on how quality reporting is working for them. The agency also evaluates measures annually to determine if they should be phased out using eight metrics, including whether a measure is topped out, if it improves outcomes, and if the cost of collection outweighs the benefits, a CMS spokesperson said.
The CMS has cut the number of quality measures by 18% since it launched a 2017 initiative under the Trump administration to reduce the number of quality measures, projecting a savings of $128 million.
The initiative’s next phase will “shape the entire ecosystem of quality measures that drive value-based care,” by addressing gaps in health care and creating measures that “reflect social and economic determinants,” the agency said. The CMS is soliciting feedback on the initiative, which has not been finalized.
The CMS made most quality measure reporting optional for the first half of 2020, as Covid-19 cases and deaths climbed, “to allow providers to focus on patient care,” a CMS spokesperson said.
Hospital staff that help with measurement reporting were often pulled to other tasks that more directly supported caring for Covid-19 patients, Elliott said. “It was appropriate for the quality measurement to kind of take a step back, a pause, so that the industry could really adjust to this new situation,” Elliott said.
The agency brought back most of the requirements in the latter half of the year with some flexibilities to support providers. The CMS also “finalized multiple rules around measure suppression for payment purposes if data demonstrated a significant impact from Covid-19,” a CMS spokesperson said.
The industry still doesn’t know what the impact of this period of missing data will be, Smith said, so the CMS should not rush to throw out measures that took many years to “identify, design, and implement.”
The pandemic has accelerated the development of electronic health records, Elliott said, and showcased “the need for some real-time information” about treatment quality. Measures are also “becoming more robust” as they digitize, representing entire populations rather than individual physicians, which reduces the burden on providers and makes them more difficult to game, Elliott said.
The CMS will continue working with stakeholders to “identify measures that are meaningful to providers, reduce reporting burden, enhance transparency and data sharing, and empower beneficiaries and their families to make informed decisions about their health care,” a CMS spokesperson said.
Mate said he hopes this period of innovation driven by the pandemic and racial justice advocacy “is not a blip” and that the industry doesn’t “go back to doing things the way we’ve always done them.”
“This is a different time, a different moment,” Mate said, and the industry now has the opportunity to “focus on what really matters.”