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External and Internal Inputs

Legislative Mandates

Most CMS quality reporting and incentive programs are born out of legislation, which in turn amend the Social Security Act. Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA), the Patient Protection and Affordable Care Act (ACA), and the American Recovery and Reinvestment Act of 2009 (ARRA), including the Health Information Technology for Economic and Clinical Health (HITECH) Act, have the largest influence on CMS’s quality measurement priorities, which have led to the broad payment reform and quality-based payment models.

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act, fully enacted in March 2010, is known as ACA.

ACA has a wide span of influence including, for example

The Institute of Medicine (2014) published the key features of the ACA by year.

American Recovery and Reinvestment Act

ARRA was an economic stimulus package that affected many sectors (e.g., federal tax relief, expansion of unemployment benefits, education, infrastructure, and health care). Title XIII of ARRA is the HITECH Act, which initiated the Electronic Health Record (EHR) Incentive Programs, now called Medicare Promoting Interoperability Programs. The primary goal of the HITECH Act was to promote and expand the meaningful use of health information technology (IT), but it also included funding for things such as workforce education and health information exchanges. Promoting Interoperability Programs provide payments to eligible clinicians (through the Merit-Based Incentive Payment System [MIPS]) and eligible hospitals if they demonstrate meaningful use of certified electronic health record technology (CEHRT) and penalize those who do not. The belief is that EHR use will improve the quality, safety, and efficiency of health care. MIPS incorporated the Medicare EHR Incentive Program for Eligible Professionals.

Improving Medicare Post-Acute Care Transformation Act

The Improving Medicare Post-Acute Care Transformation Act of 2014, commonly referred to as the IMPACT Act, required the submission of standardized data by long term care hospitals (LTCHs), skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRFs), in addition to initiating the SNF Quality Reporting Program. The IMPACT Act required nesting of specified clinical assessment domains using standardized (uniform) data elements within the assessment instruments currently required for submission by LTCHs, IRFs, SNFs, and HHAs. The Act further required that CMS develop and implement quality measures from five quality measure domains using standardized assessment data. The Impact Act also required the development and reporting of measures pertaining to resource use, hospitalization, and discharge to the community. Through the use of standardized quality measures and standardized data, the goal is to enable interoperability and access to longitudinal information for such measured entities to facilitate coordinated care, improved outcomes, and overall quality comparisons. The CMS Data Element Library is an output of the IMPACT Act and is the centralized resource for CMS assessment instrument data elements (e.g., questions and responses) and their associated health information technology standards.


Medicare Access and CHIP Reauthorization Act

MACRA of 2015 (P.L. 114-10) defined five quality domains, including (i) clinical care, (ii) safety, (iii) care coordination, (iv) patient and caregiver experience, and (v) population health and prevention. In response to MACRA and the laws it amends, CMS conducts measure priorities planning across these domains and emphasizes (a) outcome measures, including patient-reported outcome measures and functional status measures, (b) patient experience measures, (c) care coordination measures, and (d) measures of appropriate use of services, including measures of overuse.

With MACRA, Congress mandated that several quality reporting and incentive programs phase out in 2018, while MIPS would continue well beyond 2019. Under MACRA, CMS developed performance assessment methods using composite scoring for the determination of MIPS adjustment factors for all MIPS-eligible clinicians. Funding provided under the ACA for the creation of a wide array of quality measures, including outcome measures and measures for settings that are new to quality reporting such as IRFs, hospices, LTCHs, inpatient psychiatric facilities, and Prospective Payment System (PPS)-exempt cancer hospitals, supports this effort. In addition, under MACRA and ACA, Medicaid and other Department of Health and Human Services programs will continue to develop and implement quality measures. MACRA also supports the gains made under ARRA. ARRA launched a period of significant funding for the development of standards for EHRs and the widespread adoption of CEHRT across measured entities. MACRA continues this support with a mandate for widespread interoperability among these systems with requirements for CMS to develop metrics for successful interoperability. Further, MACRA requires incentives and payment penalties to encourage rapid achievement of that goal.

21st Century Cures Act

Enacted in 2016, The 21st Century Cures Act (Public Law [P.L.] 114-255) (Cures Act), aligns with many of CMS’s quality measurement priorities. The Cures Act serves largely to increase choice, access, and quality of care for patients. The Cures Act mandates efforts to reduce administrative burden on measured entities and calls for the alignment and simplification of quality measures across federal programs and other payers. The Cures Act specifically mandates the reduction of regulatory or administrative burden related to the use of EHRs and calls for the identification of priority uses for the data arising from the implementation of value-based payment programs. The Cures Act aims to increase data-sharing and interoperability via the expanded use of health IT and the creation of partnerships between health information exchange organizations and measured entities. The increase in data-sharing is also meant to increase patient access to EHRs and thus improve patient care.

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