The final version of the CMS Quality Measure Development Plan (MDP) will serve as the strategic framework for the future of clinician quality measure development to support the Medicare Merit-based Incentive Payment System (MIPS) and eligible Medicare alternative payment models (APMs). The MDP, posted by CMS on May 2, 2016, highlights known measurement and performance gaps, and recommends prioritized approaches to close those gaps through the development, adoption, and refinement of quality measures (CMS Quality Measure Development Plan, May 2, 2016).
Going forward, CMS plans to: (1) solicit input (by June of each year) from stakeholders to fill gaps by developing additional measures for MIPS; (2) use the rulemaking process to finalize an initial set of measures for the program that will be made public by November 1 each year; and (3) update the MDP, annually or when appropriate, by the development of additional quality measures to address identified gaps and other priority areas.
Background. Like the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), the passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) (P.L. 114-10) supports the ongoing transformation of health care delivery by furthering the development of new Medicare payment and delivery models for physicians and other clinicians. Section 102 of MACRA required the HHS Secretary to develop and post on the CMS.gov website, by January 1, 2016, a draft plan for the development of quality measures related to the new MIPS and to eligible Medicare APMs. CMS posted a draft plan on December 18, 2015, and solicited public comment (see CMS is developing quality one measure at a time, December 23, 2015). Responses from 210 individual and institutional commenters informed the creation of the final MDP. MACRA required the final MDP to be posted on the CMS.gov website by May 1, 2016.
MIPS. The MDP states that CMS will apply a positive, negative, or neutral payment adjustment, in a budget-neutral manner, to each MIPS eligible clinician based on a composite performance score across four performance categories: (1) quality; (2) resource use; (3) clinical practice improvement activities; and (4) advancing care information, defined in MACRA as the meaningful use of certified electronic health record (EHR) technology. CMS plans to use separate rulemaking cycles to select measures for MIPS and establish criteria for the performance categories.
To accelerate the alignment of quality measurement and program policies, MACRA sunsets payment adjustments for the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare EHR Incentive Program for Eligible Professionals at the end of 2018 and establishes MIPS beginning January 1, 2019.
APMs. MACRA established incentive payments for clinicians who are qualifying participants in advanced APMs. Advanced APMs must tie payment to quality measures comparable to the quality measures used in MIPS. Therefore, an important element of the MDP is the applicability of candidate measures to support a variety of future APMs.
Operational requirements. In the MDP, CMS details a strategic approach to the following operational requirements: multi-payer applicability, coordination and sharing across measure developers, clinical practice guidelines, the evidence base for non-endorsed measures, gap analysis, quality domains and priorities, the applicability of measures across health care settings, clinical practice improvement activities, and consideration for electronic specifications.
Quality measure development. CMS identifies key considerations for implementing the MDP, including:
- partnering with patients, caregivers, and communities in the measure development process;
- partnering with frontline clinicians and professional societies;
- aligning measures across payers;
- reducing clinician burden of data collection for measure reporting;
- shortening the time frame for measure development;
- streamlining data acquisition for measure testing;
- identifying and developing meaningful outcome measures;
- developing patient-reported outcome measures (PROMs) and appropriate use measures; and
- developing measures that promote shared accountability across settings and clinicians.
The MDP offers several collaborative approaches that CMS plans to implement to address these challenges.
Priorities and gaps. The MDP identifies initial priorities for each of the quality domains based on input from multi-stakeholder groups, recent publications, federal reports and initiatives, stakeholder input from public comment on the draft plan, and preliminary analysis of the preferred measure sets identified by specialty within the PQRS program. Through ongoing collaboration with stakeholders, and during the rulemaking process, CMS will identify additional priority topics and gaps. As such, this list will be continually refined.
The MDP lists and defines the following items as the initial priorities for measure development by quality domain:
- Clinical care. Measures incorporating patient preferences and shared decision-making, cross-cutting measures that may apply to more than one specialty, focused measures for specialties that have clear gaps, and outcome measures.
- Safety. Measures of diagnostic accuracy and medication safety related to important drug classes.
- Care coordination. Assessing team-based care (e.g., timely exchange of clinical information) and the effective use of new technologies, such as telehealth.
- Patient and caregiver experience. Patient-reported outcome measures (PROMs) and additional topics that are important to patients and families and caregivers (e.g., knowledge, skill, and confidence for self-management).
- Population health and prevention. Developing or adapting outcome measures at a population level, such as a community or other identified population, to assess the effectiveness of the health promotion and preventive services delivered by professionals; Institute of Medicine (IOM) Vital Signs topics (e.g., life expectancy, wellbeing, addictive behavior); and detection or prevention of chronic disease (e.g., chronic kidney disease).
- Affordable care. Overuse measures, such as overuse of clinical tests and procedures.
Conclusion. According to CMS, the successful implementation of the MDP depends on a successful partnership with patients, frontline clinicians, and professional organizations and collaboration with other diverse stakeholders. CMS plans to carefully balance the need for focused specialty measure development with the need for more broad cross-cutting measures. CMS’ goal is that the MDP will result in a person-centered portfolio that will be a key driver of delivery system reform, resulting in better care, smarter spending, and healthier people.
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