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CMS Reveals Their Universal Foundation for Quality Measures

 

Quality measures came together over the last several decades in a haphazard way. There wasn’t exactly an overarching strategic measure development process across all programs. Instead, measures were developed and then required based on specific circumstances and not necessarily considered as a collective. According to CMS, the massive number of measures now in circulation causes confusion, increases reporting burden, and creates misaligned approaches for common clinical issues.

CMS is attempting to reverse this trend and create a unified set of measures that adhere to national priorities. They took the first step toward this goal in 2017 with the Meaningful Measures movement which removed many duplicative measures across regulatory programs. CMS further outlined their quality measure goals in the National Quality Strategy Roadmap that they released last year. And just this March, CMS released an article entitled “Aligning Quality Measures across CMS – The Universal Foundation.”

The Universal Foundation for Quality Measures

CMS's stated goal is to align quality measures across all programs. To do this, they are proposing a building-block approach which they are calling “a universal foundation” for quality measures. This universal foundation of measures will apply to as many CMS quality and value-based care programs as possible. Additional measures will be added for different settings of care and populations. They mention everything in this report including all ~20 quality reporting programs, all settings of care (clinics, hospitals, skilled nursing facilities, LTACH, etc.) and all methods of measurement and reimbursement (e.g., health insurers and ACOs). They are aiming to align measures anywhere and everywhere.

To begin their journey to the Universal Foundation for Quality Measures, CMS started with a list of adult and pediatric measures.

Here’s a takeaway for you. CMS will be prioritizing these measures. If you can track these at your setting of care and you haven’t started tracking any of these, get started. This is the list that CMS has said is their starting base list of quality measures.

Preliminary Adult and Pediatric Universal Foundation Measures

Domain

Identification Number and Name

Adult

Wellness and prevention

  • 139: Colorectal cancer screening
  • 93: Breast cancer screening
  • 26: Adult immunization status

Chronic conditions

  • 167: Controlling high blood pressure
  • 204: Hemoglobin A1c poor control (>9%)

Behavioral health

  • 672: Screening for depression and follow-up plan
  • 394: Initiation and engagement of substance use disorder treatment

Seamless care coordination

  • 561 or 44: Plan all-cause readmissions or all-cause hospital readmissions

Person-centered care

  • 158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures

Equity

  • Identification number undetermined: Screening for Social Drivers of Health

Pediatric

Wellness and prevention

  • 761 and 123: Well-child visits (well-child visits in the first 30 months of life; child and adolescent wellcare visits)
  • 124 and 363: Immunization (childhood immunization status; immunizations for adolescents)
  • 760: Weight assessment and counseling for nutrition and physical activity for children and adolescents
  • 897: Oral evaluation, dental services

Chronic conditions

  • 80: Asthma medication ratio (reflects appropriate medication management of asthma)

Behavioral health

  • 672: Screening for depression and follow-up plan
  • 268: Follow-up after hospitalization for mental illness
  • 264: Follow-up after emergency department visit for substance use
  • 743: Use of first-line psychosocial care for children and adolescents on antipsychotics
  • 271: Follow-up care for children prescribed attention deficit–hyperactivity disorder medication

Person-centered care

  • 158 (varies by program): Consumer Assessment of Healthcare Providers and Systems overall rating measures

 

Taking the building block approach, CMS intends to identify “add-on” measures based on the setting of care – for instance hospital-based care, maternity care, dialysis care, long-term care, and community services. These add on measures ideally are applicable in most situations, but CMS recognizes that’s not always possible. For instance, the MVP reporting framework in the Quality Payment Program is designed with specialty care in mind. CMS specifies that in some instances, like MVP reporting, a measure may only be applicable for that one program.

CMS also stresses that they intend to move toward using more outcome and patient-reported measures for which data can be collected and reported digitally.

A Review of Measure Types

Let's take a step back and make sure we are altogether on this last point. There are several different measure types in circulation. Some of the differences come down to semantics, but let's review the four major measure types here.

Structural Measures

Structural measures assess features of a healthcare organization relevant to its capacity to provide healthcare. This type focuses on the environment of care and its related administrative processes and policies. For example, the Maternal Morbidity measure required this year as a part of the IQR program asks hospitals to attest "yes" that they are currently participating in a Perinatal Quality Improvement (QI) collaborative and they are implementing patient safety practices or bundles related to this initiative. Note that the new Social Drivers of Health (SDOH) measures are considered structural measures as well but Medisolv is calculating these for our clients as eCQMs.

Process Measures

Process measures, which are what most of the past and current eCQMs are considered, are indicators of how a health care organization maintains or improves health. As defined by CMS, process measures are the evidence-based best practices that represent a health system’s efforts to systematize its improvement efforts. Examples of process measures include the VTE measures (e.g., Venous Thromboembolism Prophylaxis (CMS108)) and the stroke measures (i.e., Discharged on Antithrombotic Therapy (CMS104)).

Outcome Measures

Outcome measures reflect the impact of the health care service or intervention on the health status of the patients. The current hybrid measures that track readmission and mortality rates are examples of outcome measures. The “outcome” is a result of many factors, some of which are beyond a hospital’s control. Because of that, we have “risk-adjusted” measures to compensate for those uncontrollable factors.

CMS began shifting to more outcome-based measures a few years ago. When electronic measures were first introduced, they were mostly process measures. Over time, these measures have provided data to help hospitals improve their quality of care. Outcome measures are typically considered more of an indicator of quality of care, but as previously stated, these measures are also subject to factors not directly within the control of the hospital.

Patient-Reported Outcome-Based Performance Measures

Patient-reported outcome-based performance measures (PRO-PMs) are measures that calculate an outcome as defined above but they contain Patient-Reported Outcome (PRO) information. Here's where we get into semantics. There are PROs, PROMs (Patient-Reported Outcome Measures) and PRO-PMs. Here's an article from CMS that explains the difference. Basically PROs are the things patients directly report, PROMs are the tools used to collect those PROs and the PRO-PMs are the way to meaningfully aggregate that data into a measure. For instance, the first ever PRO-PM required for the IQR program in 2025 is the Hospital-Level Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) PRO-PM. This measure assesses the number of patients who experience substantial improvement after surgery. This gathers data from different sources including how the patient reported their quality of life before and after surgery for their hip or knee. 

The Future of Quality Measures

What does this mean for you? Maybe nothing quite yet, but keep in mind that CMS very specifically states that they are moving away from structural and process measures to more outcome and PRO-PM types. We suggest taking a survey of all measures you are responsible for tracking. Review which types of measures are in your environment. Are they mostly structural or process? Are there places you can incorporate outcome measures? Could you participate in the voluntary reporting of the PRO-PM this year?

Here's another consideration for you. CMS has stated in this article and in their National Quality Strategic Roadmap that they are moving as quickly as they can to a fully digital way of reporting. So while your SDOH measures are structural now, there's a high likelihood that these will become electronic in the future. In fact, that’s why Medisolv designed these SDOH measures to calculate as eCQMs for our clients. We understand that CMS is headed that direction anyway. It's time to start moving toward a more outcome and patient-focused style of measurement.

 

MEDISOLV's NEW Equitable Care Module CAN HELP 

Did you know that our ENCOR platform’s new Equitable Care Module lets you stratify your data and fulfill today’s health equity measure requirements with unprecedented speed? We've turned the SDOH structural measures into eCQMs for you so you don't have to come up with a brand new way of reporting. Check out these resources to learn more, or contact us to schedule a 1:1 info session.

 

 

Karen McLaughlin

Karen McLaughlin is a Clinical Quality Advisor for Medisolv. She has worked with Medisolv for three years and previously spent 20 years working in a hospital setting eventually becoming the Senior Clinical Analyst. Karen helps Medisolv clients implement, monitor and improve their eCQM performance.

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