Feb. 16, 2023, Cindy Borgmeyer — CMS has taken a step toward reducing administrative burden for physicians by launching an initiative to standardize and better align measures used to report quality performance across its many health care programs. Dubbed the Universal Foundation, the initiative also aims to support the agency’s efforts to advance health equity by focusing on measures that can be adapted to recognize and track disparities in care among and within specific patient populations.
The AAFP has long protested the U.S. health care system’s scattershot approach to quality measurement, which requires physicians to report on multiple sets of disparate performance quality measures across a wide array of private and public payers, and continues to press for reform. As recently as last October, the Academy responded to a CMS proposed rule by urging the agency to “meaningfully streamline administrative requirements by aligning quality measures across payers.”
According to a commentary published online Feb. 1 by The New England Journal of Medicine, the Universal Foundation is part of CMS’ efforts to implement the vision outlined in its National Quality Strategy. In addition to the goals noted above, the program is intended to:
Penned by the leaders of several CMS centers, including the Center for Medicare and Medicaid Innovation, the commentary states that this new approach is designed to resolve the conundrum of balancing the need for comprehensive measurement with the desire to avoid undue burden for clinicians.
“Since there is tension between measuring all important aspects of quality and reducing measure proliferation,” the authors wrote, “we are proposing a move toward a building-block approach: a ‘universal foundation’ of quality measures that will apply to as many CMS quality-rating and value-based care programs as possible, with additional measures added on, depending on the population or setting.”
CMS operates more than 20 such programs, each with a specific participant focus (e.g., individual clinicians, health care settings such as hospitals or skilled nursing facilities, and value-based entities such as accountable care organizations) and raft of quality measures. Some measures are shared across different programs; others are not. In addition, while insurers often use many of the same quality measures CMS has adopted, others use modified or different measures.
To mitigate the challenges posed by CMS’ current use of multiple processes for measure selection and approval across its constituent centers, the agency has created a cross-center working group charged with coordinating these processes and developing and implementing aligned measures.
Currently, the working group has identified nearly two dozen preliminary quality measures across 10 domains for the Universal Foundation’s adult and pediatric components. Both components include measures in these four domains:
The adult component also includes quality measures related to seamless care coordination and equity.
“The streamlined measures included here would be used across CMS programs and populations, to the extent that they are applicable and in keeping with legislative statutes,” said the article’s authors.
The measures selected to date underlie many of the health problems associated with excess morbidity and mortality in the United States, such as diabetes, hypertension and cancer, and reflect the importance of high-quality preventive care. In addition, the authors noted, “Identification and treatment of depression and substance use disorders are included in the Universal Foundation because addressing these behavioral health conditions in an integrated way can improve both physical and behavioral health outcomes.”
According to the commentary’s authors, the agency anticipates a need to identify additional measures to assess care provided to specific populations or in certain settings, such as hospital-based care, maternity care, dialysis care, and long-term and community services.
“Our intention is that the Universal Foundation will eventually include selected measures for assessing quality along a person’s care journey — from infancy to adulthood — and for important care events, such as pregnancy and end-of-life care,” they said.
As for organizations that develop and endorse quality measures, CMS anticipates that they will be able to use the Universal Foundation to identify areas the agency has prioritized for measurement and reveal gaps.
The authors of the NEJM article stated that the Universal Foundation measures set will evolve over time, noting that CMS will consider replacing or removing measures when appropriate (e.g., when quality goals within a given category are met). “We also intend to move toward using more outcome and patient-reported measures and measures for which data can be collected and reported digitally,” they said.
According to Karen Johnson, Ph.D., vice president of the AAFP Division of Practice Advancement, CMS’ action — while well-intentioned — falls short of the mark.
“While we appreciate the intent of this announcement, focusing on a smaller number of existing measures that fail to recognize the value of primary care may be a viable interim step but should not deter us from pursuing long-term approaches that better reflect the holistic impact of primary care on outcomes that we care about — better health, smarter spending and healthier people,” Johnson said.
Two AAFP members voiced similar thoughts. AAFP News reached out to Jeffrey Susman, M.D., interim dean of the John Sealy School of Medicine at the University of Texas Medical Branch at Galveston health system, UTMB Health, and professor of family medicine. Susman, who also is a member of the National Quality Forum’s Consensus Standards Approval Committee, as well as its Behavioral Health and Substance Use Standing Committee, described a recent encounter with quality administrators at UTMB Health.
“I entered a room housing our health system quality administration and was facing dozens of charts and graphs, each depicting our performance vis a vis an insurer’s metrics,” he recalled. “Blue Cross here, United Healthcare there, Medicaid Managed Care … each assessed different metrics, varying targets and disparate denominators.
“Imagine a day when this plethora of approaches can be reduced to a handful of meaningful measures,” Susman mused. “CMS has taken an important, if imperfect, step in that direction.”
Noting that CMS is just one payer among many, Johnson added, “To have meaningful impact, other payers must follow CMS’ lead in adopting the Universal Foundation — as a starting point. Ultimately, we need payers to align around measures that truly reflect the value of primary care, and these measures don’t get us there.”
Katherine Lichtenberg, D.O., M.P.H., of St. Louis, Mo., is a member of NQF’s Geriatrics and Palliative Care Standing Committee and former chair of the AAFP Commission on Quality and Practice. She also shared her thoughts on this first round of Universal Foundation measures, acknowledging the challenges of winnowing a vast collection of quality measures down to the bare bones.
“There are so many conditions to consider, and then we have to condense that down into what can have a positive impact for patients and how burdensome it will be for physicians to collect the data,” she said. “There are not as many outcome measures as I was hoping to see but collecting the data for many of those measures was going to take a lot of effort.”
Another sticking point, Lichtenberg added, was the difficulty inherent in bringing together a diverse group of stakeholders to do the work.
“There was primary care representation, but there were also many specialists, and the different disciplines were not always on the same page,” she noted. “The patient and patient advocates were a strong voice. It was not easy to find the balance between what patients and their advocates were looking for and what physicians thought they could do to impact things.”
Realistically, Lichtenberg said, “No one is going to be happy when the intent is to develop universal measures. Different groups have different priorities (including the patients). This is a decent jumping off point, but I see this process continuing so the measures can be refined.”
Susman largely agreed with that sentiment.
“Does the initial measure set capture the unique value of primary care?” he asked. “Are all of the quality metrics meaningful to patients? Are all the important dimensions of care captured? No.
“But I believe acknowledging that we have a problem and taking a first step toward parsimony is a path worth walking.”
As for next steps, Lichtenberg echoed the hope that “private payers will follow CMS and use these same measures so we can finally work toward a harmonized set of measures.” She also said future work in this area must take a more patient-oriented approach.
“Outcomes measures are what we need to work toward,” she observed. “It’s great if 80% of a physicians’ practice has been screened for colorectal cancer, but if they are unable to access services to treat that cancer, what is the point of screening? There is a lot of opportunity to address the social determinants of health, but we need to be ready then to do something about the disparities we find.”
The AAFP continues to champion the Person-Centered Primary Care Measure introduced in 2019 by The Larry A. Green Center, which uses a comprehensive and parsimonious set of 11 patient-reported items to assess the broad scope of primary care. Part of the Measures That Matter to Primary Care initiative, the PCPCM measures the high-value aspects of primary care based on a patient’s relationship with the physician/clinician or practice. The PCPCM has been endorsed by CMS and NQF and became available for use as a Quality Payment Program Merit-based Incentive Payment System clinical quality measure in 2022.
Lichtenberg said she hopes her fellow family physicians will consider taking an active role in the process of developing, vetting and implementing future measures.
“I would have liked to see even more primary care physicians participating” in CMS’ initiative, she noted. “I know we are one voice of many, but we need to take every opportunity we have to be involved in this type of work.”