Key Contributions
A variety of sources contribute to and guide CMS measure development, selection, and review including interested party input, U.S. legislative mandates, and CMS priorities. The rulemaking process is a prime example of how these inputs come together to support quality measurement. For this process
- Section 3014 of the Patient Protection and Affordable Care Act requires a pre-rulemaking process in which the CMS-contracted Consensus-Based Entity must convene interested parties to provide input on the Measures Under Consideration (MUC) List.
- The public then provides comments on the MUC List, and CMS may propose measures from the MUC List for use in a CMS program through the rulemaking process.
- The public may submit comments to CMS regarding the measures in proposed rules. Once CMS has considered all public comments, CMS may finalize (adopt) the measures in a final rule.
The next sections provide additional details about interested party input and legislative mandates.
Persons, Public, and Other Interested Parties
CMS conducts its measurement activities in a transparent manner. The information gathered through various methods described in Measure Conceptualization, informs the Department of Health and Human Services and CMS about future measurement needs. Additionally, Section 101(f) of Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) requires CMS to solicit, accept, and respond to input from interested parties, including physician specialty societies, applicable practitioner organizations, and other interested parties for episode groups (i.e., care episode groups and patient-condition groups).
Care episode groups include those individuals whose care included similar treatments and procedures, taking into consideration individuals’ clinical diagnoses and problems during the care episode; care setting; level of acuity; and principal procedures or services furnished.
Patient-condition groups include those individuals with similar conditions, taking into consideration individuals’ medical and surgical histories, comorbid conditions, overall health status, and eligibility or dual-eligibility status.
Persons and families are extremely important interested parties in the quality measurement enterprise, and CMS is committed to gathering their input during priorities planning. More detail about ways to hear the individual's voice is found in the Person and Family Engagement section and the Person and Family Engagement in Quality Measurement supplemental material. Persons, families, patient advocates, and subject matter experts are encouraged to participate in technical expert panels, focus groups, and public comment opportunities.
Through all these activities, individuals, families, and caregivers; measured entities; payors; specialty societies; advocacy groups; states; health plans; and other interested parties and experts with an interest in quality can help shape CMS policy and prioritization and planning of measures.
Legislative Mandates
Most CMS quality reporting and incentive programs are born out of legislation, which in turn amends the Social Security 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 a large influence on CMS’s quality measurement priorities, which have led to 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
- Greatly expanding access to health care coverage through numerous provisions and establishing the Center for Medicare and Medicaid Innovation (CMMI), health exchanges, shared savings program
- Numerous new quality reporting and incentive programs such as the Hospital Readmissions Reduction Program, Inpatient Psychiatric Facility Program, and the Hospital Value-Based Purchasing Program
- ACA prohibits health plans from rescinding coverage except in the case of fraud or intentional misrepresentation
- Requires health plans to extend dependent coverage to unmarried adult children up to the age of 26 years
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 EHR 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.
- Resources
A selection of internal and external sources of inputs.