Inside the CMS plan to streamline quality measurement

Modern Healthcare – Monday, December 23, 2024
By Bridget Early 

Quality measurement is burdensome and complicated. The government and the private sector are struggling to figure out a good fix.

The Centers for Medicare and Medicaid Services uses quality data to inform its reimbursement rates, so it’s a high-stakes matter for providers and health insurance companies. CMS has proposed an overarching framework meant to streamline the process: the Universal Foundation.

The Universal Foundation is meant to ease the burden on providers and insurers by establishing standardized metrics while sustaining incentives that promote high-quality care, according to CMS.

“Proliferation of quality measures has caused confusion, increased reporting burden and misalignment of approaches for common clinical scenarios,” senior CMS officials including Center for Medicare Director Dr. Meena Seshamani wrote in the New England Journal of Medicine in February 2023, when the agency issued a draft version of its plan.

Here’s what to know about the Universal Foundation.

What is the Universal Foundation?

The Universal Foundation consists of two dozen quality measures across several categories that track wellness and prevention, chronic conditions, behavioral health, and “person-centered” care.

Those include measures of breast and colorectal cancer screenings, blood pressure, blood sugar levels, vaccinations, and hospital readmissions.

CMS sought metrics relevant to common ailments and preventive care, and continues to solicit recommendations for additional measures.

CMS has incorporated this framework into recent regulations such as the Medicare Advantage final rule for 2024 and the Physician Fee Schedule final rule for 2025.

The agency plans to expand the Universal Foundation’s reach to Medicare Advantage, Medicaid and the health insurance exchanges, and requested comment on adding it to the nursing home and home health payment systems.

Why did CMS create the Universal Foundation?

This is CMS’s latest effort to counter a phenomenon known as “measure cacophony,” in which conflicting quality metrics vex providers and insurers.

Providers and health insurers face varying requirements for collecting and reporting data that are “burdensome,” said Dana Gelb Safran, president and CEO of the National Quality Forum. In addition, they are expected to demonstrate meaningful performance improvements over time, she said.

Pay-for-performance quality measurement gained traction in the early 2000s, Safran said. As this grew in popularity, so did the number of discordant measures, she said.

CMS uses about 20 measure sets that encompass hundreds of discrete measures. That means providers and insurers are subject to myriad requirements for data collection and reporting and quality improvement, Safran said.

Has the Universal Foundation helped?

The Universal Foundation shows signs of success, Safran said.

“I was at a National Academy of Medicine meeting in May that was on the future of performance measurements, and that was the first time I’ve ever been in a room where I’ve heard folks say, ‘You’re starting to feel the difference in measure alignment,’” Safran said.

But Dr. Jose Figueroa, associate professor of health policy and management at Harvard University, said the framework hasn’t done much to alleviate reporting burdens. In primary care, it’s actually gotten worse, he said.

“Everybody generally agrees with the concept that having a common set of quality measures that are simple and that matter — it makes sense,” Figueroa said. “Once you agree on that, the harder part is understanding which measures make the most sense and why.”

What else might work?

The private sector is split over how much standardization is appropriate.

Blue Cross Blue Shield of Massachusetts, for instance, believes CMS should defer to state-based entities such as the Massachusetts Quality Measure Alignment Taskforce, said Dr. Mark Friedberg, the insurer’s senior vice president of performance measurement and improvement.

“All of this is a local game,” Friedberg said. “All of it is state-based or, for very large states, there may even be like Northern California versus Southern California-type alignment. It’s a mistake to think this can be dictated from D.C., and that will kind of create a lot of unnecessary measure misalignment.”

That approach would make matters worse for healthcare companies that operate in multiple states, however, Safran said.

Will Trump retain the Universal Foundation?

Simplifying quality measurement isn’t a partisan issue, said Elinor Hiller, a partner at Alston & Bird who was a CMS official during President-elect Donald Trump’s first term.

For instance, the Trump administration’s Meaningful Measures initiative sought to reduce the administrative burden, Hiller said.

Likewise, the physician reimbursement rule in 2020 introduced Value Pathways, a quality reporting option CMS said would save providers and insurers 2 million hours a year. The agency implemented the initiative in 2023 under President Joe Biden.

Yet some conservatives want to see the next Trump administration rethink quality measurement. CMS should be limited to publicly sharing quality data while private sector actors should be responsible for enforcing accountability, said Joe Albanese, a senior policy analyst at the Paragon Health Institute who worked in the White House Office of Management and Budget under Trump and Biden.

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