By Rebecca Mayo, J.D.
A review of the CMS quality measurement activities found a lack of procedures to analyze measure impact on the program’s strategic objectives and that the databases used to track funding contained incomplete data.
CMS quality measures have significant consequences because they determine whether many health care provider receive an adjustment in their Medicare payments. An HHS Office of Inspector General (OIG) review found CMS’s system for tracking and evaluating these quality measurement activities could be managed more effectively. The OIG recommended that CMS maintain more complete and detailed information on its funding for quality measurement activities, establish procedures to systematically assess measures under consideration and develop performance indicators to evaluate progress in achieving its objectives (GAO Report, GAO-19-628, September 20, 2019).
Quality measurement programs. In the early 2000’s, CMS began offering financial incentives to provider receiving Medicare payments who report their performance on specified quality measures. For example, providers may receive higher payments if they report their performance on the quality measures or their payment may be affected by their performance on the quality measures. These programs are based on quality measures that assess different aspects of health care quality such as the extent to which provider effectively implement clinical practices that have been shown to result in high-quality or efficient care. While others track the results of health care, such as mortality, infections, and patients’ experiences of that care. CMS has its own set of quality measures, however different entities may develop new health care quality measures so CMS developed a set of guidelines for developing new quality measures in the Blueprint for the CMS Measures Management System.
In 2017 CMS announced its Meaningful Measures Initiative which revised its strategic objectives for the measures CMS develops or uses in its Medicare quality programs. The Meaningful Measures Initiative included 19 specific meaningful measure areas to provide greater specificity for its objective to address high-impact measure areas that safeguard public health.
Tracking funding. The OIG found that CMS maintains information in its core budget database on the amount of funding for its quality measurement activities, however the database does not capture all of the funding the agency has obligated or the extent to which this funding has supported the strategic objectives. The funding obligated is identified in the database either as coming from appropriations specifically designated for quality measurement purposes or funding that came from appropriations for more general purposes but had specific project codes to identify its use for quality measurement activities. However, some activities could not be identified by project codes. Further, the database is not sufficiently detailed to show the extent to which the funding was used for activities that support the strategic objectives. The database also shows that CMS maintained substantial unobligated balances from 2010 through 2018, meaning that CMS did not use that money the year it was appropriated and it remained available for use in future years.
Promoting strategic objectives. The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) defines an annual process for CMS to select measure to be used in its Medicare quality programs. CMS internal guidance outlines indicate that the strategic objectives should be considered when deciding if a measure should be accepted or rejected. However, the decision to remove an existing measure relies only on measure developers to monitor the performance of their measures based on principals defined in the Blueprint.
While the OIG found that CMS has taken some steps that provide opportunities for CMS officials to consider how quality measures may help address the agency’s quality measurement strategic objectives, it found that it lacks procedures to ensure systematic assessment of each quality measure against each of its eight quality measurement strategic objectives. Further, CMS lacks procedures to ensure a systematic assessment of whether the collective set of measures will help achieve each of the objectives. CMS has also failed to develop and implement performance indicators that would be needed to determine if it is making progress in meeting is quality measurement strategic objectives.
Recommendations. The OIG recommended that CMS maintain more complete information on both the total amount of funding allocated and the extent to which the funding supports each of its quality measurement strategic objectives. CMS should also develop and implement procedures to systematically assess the measures it is considering developing, using, or removing in terms of their impact on achieving the strategic objectives. Finally, CMS should develop and use a set of performance indicators to evaluate the agency’s progress towards achieving its quality measurement strategic objectives. HHS concurred with the recommendations and has undertaken a review of its processes.
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