The Universal Foundation – searching for shared priorities in quality measurement
Post Written by Ken Robin, Chief Data Analyst
Through its National Quality Strategy and new Universal Foundation, CMS attempts to create order from chaos as it relates to measuring quality across programs, providers, contracts, and patient experience.
In the wake of the COVID-19 Public Health Emergency, CMS is grappling with the monumental question of what can be learned and what can be improved to ensure that all Americans receive safe, equitable, high-quality health care. To organize thinking and define some pillars, the agency released a National Quality Strategy, and subsequently the initial outline of a long-term effort to align/streamline quality measurement. Quality as a concept has worked its way into every significant discussion of policy or practice in the health care sphere, encompassing key components such as equity, alignment, innovation, technology, safety, and engagement. In the abstract, these goals are almost universally lauded, but the devil is indeed in the details, and of course ideals are far easier to proclaim than to rigorously pursue.
National Quality Goals
CMS loosely defines quality as:
“Quality includes, but is not limited to, ensuring optimal care and best outcomes for individuals of all ages and backgrounds as well as across service delivery systems and settings, including preventive, acute, chronic, and long-term care with a focus on health-related social needs.”
Further complexity is introduced by the recognition that quality must extend to all payer types, as well, including all forms of Medicare and Medicaid, CHIP, and Marketplace plans. The National Quality Strategy proposes that the following goals weave their way through this tangled web of systems, settings, and payers:
Embed quality into the care journey: Using a person-centered approach, understand unique challenges and barriers across the lifespan and acknowledge interconnectivity of physical, behavioral, and social needs.
Advance health equity: True quality cannot exist without equity, and the PHE highlighted some stark disparities and injustices. CMS is testing approaches that incentivize access and promote quality for historically underserved communities.
Promote safety: Quite simply, this goal calls out the continuing need to address systemic flaws that lead to health care errors resulting in harm or death.
Foster engagement: All stakeholders have access to meaningful data so that they can be part of informed decision-making processes. This goal touts the value of collaboration and trust among providers, patients, caregivers, and payers.
Strengthen resiliency: Though resiliency is a term that needs further definition, this goal grew largely out of the PHE, during which workforce shortages, insufficient quality assurance, and systemic rigidity were mercilessly exposed.
Embrace the digital age: Increasingly anachronistic with each passing year, the goal here is to build an interoperable, shared, and standardized system that feeds timely and secure information across the health care landscape.
Incentivize innovation and technology adoption to drive care improvements: Essentially, this goal challenges the health care system to behave as a science, engage in the scientific method, and use evidence and data to drive improvement. Importantly, CMS specifies that evidence must be collected from all populations and applied appropriately with sensitivity to the possibility of differential impacts.
Increase alignment: The move to value has contributed to a confusing mix of programs, policies, and metrics, at times impeding understanding of impact. CMS proposes to largely take on this goal itself by developing a transparent approach to aligning performance metrics. The agency further promises a simplified national picture of quality measurement that patients, providers, and payers all understand.
A Building Block for the Future of Quality Measurement: The Universal Foundation
Quality measurement has been described as a “movement” in health care, which carries both positive and negative implications. On the plus side is the overwhelming consensus that quality in health care must be better understood, tracked more rigorously, and is necessary to demonstrate value. Unfortunately, once an idea becomes a “movement”, it often gathers momentum too quickly and spirals a bit out of control. In the past 20 years the proliferation of quality measurement has been rapid and disjointed, with CMS now operating more than 20 quality programs with their own sets of measures. Insurers have added to the mix, with some using CMS measures and others creating their own or modifying existing formats. To alleviate reporting burden and improve understanding of outcomes, CMS is proposing a “universal foundation” of measures that will serve as the initial building block of quality for as many programs as possible.
The Universal Foundation is part of the CMS quality vision and is put forth as fundamental to the pursuit of alignment, equity, digitization, and value. A cross-sector working group reviewed the disparate processes used to select and approve measures for various uses and set about developing a consistent approach to define the Universal Foundation. A preliminary set of adult and pediatric measures was released earlier this year, intended for use across CMS programs and populations. Ten adult measures were identified across domains of Wellness and Prevention, Chronic Conditions, Behavioral Health, Seamless Care Coordination, Person-Centered Care, and Equity. The equity piece centers on screening for social drivers of health. Thirteen pediatric measures were selected, also broken out into domains of Wellness and Prevention, Chronic Conditions, and Behavioral Health, and Person-Centered Care. The Person-Centered Care measure for both age groups is an overall CAHPS (Consumer Assessment of Healthcare Providers and Systems) rating.
The Universal Foundation will serve as exactly what the name suggests – a common starting point upon which additional measures will be added depending on the population and service being assessed. Add-ons specific to settings such as hospital care, maternity care, or long-term care will be necessary, since true quality of specialty care cannot be captured in a common measure set. The Foundation is an attempt to streamline the collection of data associated with the highest impact conditions and practices. Examples include cancer, diabetes, preventive care, behavioral health, and care coordination.
The proposed measure set is preliminary and fluid. As our ability to measure certain outcomes improves, or quality goals are achieved, or critical gaps in care are identified, the Universal Foundation will respond to these contextual changes. CMS is soliciting feedback through listening sessions, requests for information, and other interactions with both the medical community and public. The agency stresses that any changes to Medicaid or CHIP measure sets will be made in consultation with states. For now, the Universal Foundation is the first card on the table in what is sure to be a lengthy process of negotiation and trial and error.
Ultimately, aligning a disjointed health care system is a noble and worthy goal. Even partial success has the potential to drastically improve outcomes and reduce disparities for some of population health’s most stubborn metrics.
If you need help understanding, measuring or applying quality metrics that your organization is accountable for, HSG is here to help. We support a wide variety of clients in their quality strategy; drop a line and let’s chat.
About the Author: Dr. Ken Robin is the Chief Data Analyst at Helgerson Solutions Group. Connect with him on LinkedIn.