CMS Measures Itself on Quality: Thoughts from CMS QualCon2024
This post was written by Dr. Ken Robin, Chief Data Analyst.
As CMS continues to work through its quality strategy, key changes are being made, including a major hint that future CMMI models will focus less on cost-reduction and more on improving quality.
Another annual CMS Quality Conference has come and gone, with a lot of ground covered by the quickly moving train that is the CMS National Quality Strategy, articulated by the programs, policies, and priorities put forth by its various centers.
The CMS Quality Strategy has four priority areas:
1. Equity and Engagement (whole person, patient-centered care)
2. Safety and Resiliency (commitment to zero harm and responsive systems)
3. Outcomes and Alignment (measurable results and coordination across settings)
4. Interoperability and Scientific Advancement (data-driven, tech-enabled science)
From designing care models, to delivering services, to measuring and reporting outcomes, these quality threads run through all aspects of CMS’ work. Some take homes from QualCon are that while a tremendous amount of work is underway to address and improve quality, not all destinations have been fully defined. Plenty of opportunities for improvement remain, and the pursuit of optimal health care quality for all probably has no real end point. Good data are more likely to point to better questions than to reveal definitive answers, so we’ll be riding this train together for the long haul.
The CMS approach to quality can’t be discussed without touching on basically all other aspects of health care delivery. If “the highest level of health for all people” is the goal, then commitment to quality becomes a guiding principle that is woven into thinking on access, equity, data, safety, and cost. These elements are interdependent and linked like cars on our aforementioned train, so CMS rightfully addressed each of them in some detail at QualCon 2024.
Quality as Access
Not surprisingly, access was identified as a particular area of concern for Medicaid. In the context of The Great Unwinding (i.e. the reinstatement of annual eligibility verification for Medicaid members), Medicaid enrollment in many states has dropped steeply, pointing to coverage and access as top priorities for the program. The point was made that quality and access need each other if either is to matter. If every best practice for service delivery is followed but patients don’t come through the door, no one benefits. Full waiting rooms and sub-optimal care is an equally ineffective combination. Coverage and access, it seems, are necessary pre-existing conditions that tie quality of care to outcomes that matter.
Quality as Equity
Equity was another thread woven into the tapestry of the desired state of health care delivery. Access means access for all, and can quality without equity even exist? The message at CMS QualCon 2024 was no. Equity and engagement is one of the four pillars of the CMS Quality Strategy, and the Department of Health and Human Services further affirmed that equitable access to quality was a top priority. Discussions of equity spilled over to the growing emphasis on, and financing directed to Social Determinants of Health (SDOH) and Health Related Social Needs (HRSN). If an individual’s HRSNs result from their community’s underlying SDOH, or the set of systems and conditions defining daily life, then these concepts are intended to address inequity at its core. Economic policies, development agendas, social norms and policies, as well as political systems all drive the patterns and distributions of SDOH throughout the nation. Needs such as food insecurity, housing instability, and unemployment create and exacerbate health disparities. Any legitimate approach to overall quality must seek to address and ameliorate these disparities.
Discussions of equity also included the topics of maternal and nursing home care. Birth outcomes for both mothers and babies are notoriously inequitable, even when economic factors are controlled. CMS celebrated that nearly all states have extended Medicaid postpartum coverage to 12 months. The (still in development) criteria for earning a “birthing friendly” hospital designation was also touted as progress. Safety and quality in nursing homes was called out as a top priority of the HHS OIG. Conditions of care for institutionalized elderly were laid bare by the COVID-19 public health emergency, and these harsh revelations have directed resources to both research and address patient safety and quality of life.
Quality as Data
Data was addressed as the foundation upon which knowledge and improvement must rest. We understand access, quality, and equity only as well as available data allow. Particularly regarding equity, the Center for Minority Health Services called out the need to expand the collection, analysis, and reporting of standardized data that are appropriately stratified to reveal disparities. Only in possession of this information can we explore causes and build capacities to address those disparities. Given that patients are not, and will not be required to report demographic information, analytic approaches that compensate for missing data will be an important component to creating an accurate picture around equity.
Other common data issues were stressed, such as interoperability or building bridges to connect current data silos. Alignment across centers and quality initiatives is gradually increasing as Core Measure Sets are developed. Conference attendees celebrated the announcement that those “excel spreadsheet in 8-point font” with 600 measures would soon be whittled down to a more manageable set of outcomes.
Quality as Safety
Patient safety is another thread that wove through discussions of data, equity, quality, and AI. A renewed commitment to zero harm was stressed, not just pertaining to medical procedures, but to all types of interactions with patients, in person or virtual. The key point around safety was that the potential to inflict harm exists and must be acknowledged in all aspects of patient, provider, and system interactions. Even beyond personal interactions, harm can be caused through the collection, storage, and use of patient information. Studies were cited from 2008 and 2018 showing clearly concerning harm rates, so CMS agencies are responding and stay tuned for the next large-scale study to see if rates have improved.
Quality as Cost
Quality and cost are the two considerations that drive the work of the Center for Medicare and Medicaid Innovation (CMMI). The center is tasked with designing, implementing, and testing new health care payment models. CMMI tests and certifies models if they prove to either:
1. Lower cost of care without negatively impacting quality, or
2. Improve quality without increasing cost
Over the last decade, CMMI has primarily focused on option #1, certifying models that first and foremost lower cost, with quality tracked to ensure baseline levels are at least maintained. The hope and expectation is that in coming years the center will shift more to option #2, and work to define pathways to test, certify, and expand models based primarily on quality. If this change occurs, it will be interesting to see how CMMI structures these quality-driven APMs in coming years. In theory, true quality improvement should generate savings, or at least so says the philosophical underpinning of value-based care. The CMS quality pathway should further illustrate that the elimination of long-term cost generated by lower quality care is one of the elusive keys to efficiency in health care delivery.
Quality as Quality
With all of that said, at some point we get down to defining and tracking quality metrics. CMS continues to push to streamline, standardize and align across programs, using the Adult and Child Core Measure Sets as a foundation. They are also changing with the times as they develop measures for social drivers of health, expand focus on patient-reported measures, and work with NCQA on a HEDIS measure to capture HRSN screening.
When access, equity, data, safety, and cost are considered as interwoven elements of quality, tracking and improving care can feel dizzyingly complex. However, as nearly 100 research posters and three days of presentations at CMS QualCon would attest, a course has been charted and at least a framework for goals defined. Thousands of creative and motivated minds gathered in Baltimore were provided an outline of policies, programs, and priorities designed to pursue those goals. Progress was celebrated, shortcomings acknowledged, and the pursuit of quality rightfully presented as an ongoing cycle of testing, learning, and improving. The hope is that if we continue to learn, guided by the right principles and ideals, then perhaps safe, high quality, equitable, patient-centered care for all will prove more than aspirational.
Questions about quality measurement, measure sets, or the CMS approach? We’re here to help you & your teams align to the best quality strategy that meets your needs. Reach out and let’s chat quality!
About the Authors: This post was written by Dr. Ken Robin who is the Chief Data Analyst at HSG.
