Quality Measures

MIPS Measures Reference Guide

The MIPS Measures Reference Guide will help you select measures appropriate for your practice.

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Quality measures are “tools that help us measure or quantify health care processes, outcomes, patient perceptions, and organizational structure and/or systems...”1 They may also be called performance measures. The American Academy of Family Physicians’ (AAFP) policy states the primary purpose of performance measurement should be to identify opportunities to improve patient care. View our full list of criteria of a performance measure.  

Why Measure?

Measures inform us about how the health care system is performing. Measures help identify weaknesses, prioritize opportunities, and can be used to identify what works and doesn’t work to drive improvement. Measures can also prevent the overuse, underuse, and misuse of health care services and can identify disparities in care delivery and outcomes. Measures are used for quality improvement, benchmarking, and accountability. Measures are becoming increasingly important relative to payment as the U.S. health care system shifts away from traditional fee-for-service toward payment focused on the value of care.

What are the Types of Measures?

The table below defines and provides examples of some common measure types.

TypeDefinitionExamples
Type: StructureDefinition: A measure that assesses infrastructure, characteristics, or features of a health care organization or clinician relevant to capacity to provide health care, such as equipment, personnel, or policies.Examples:
  • Percent of providers using an electronic health record (EHR)
  • Staff-to-patient ratio
  • Percent of diabetic patients tracked in a registry
Type: ProcessDefinition: A measure that focuses on steps that should be followed to provide good care. There should be a scientific basis for believing the process, when executed well, will increase the probability of a desired outcome.Examples:
  • Ischemic vascular disease: use of aspirin or another antithrombotic
  • Colorectal cancer screening
  • Medication reconciliation
Type: Outcome (including intermediate outcome)Definition: A measure that assesses the results of health care, such as clinical events, recovery, and health status. Outcomes can be negative or positive. An intermediate outcome is an indicator or result that leads to a longer-term outcome.Examples:
  • Optimal asthma control
  • Diabetes long-term complications admission rate
  • Controlling high blood pressure
Type: Patient-reported Outcomes-Performance Measures (PRO-PMs) and Experience of Care Measures
Definition: A special outcome measure of a patient’s health status, quality of life, health behavior, or experience of care using information that comes directly from the patient, family, or caregiver without interpretation by a clinician or anyone else.Examples:
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS): patient experience
  • Gains in patient activation scores (PAM) at 12 months
  • Depression remission at 12 months
Type: Resource Use/Cost/Efficiency
Definition: Measures that assess the cost of care, resources used (people, supplies, etc.) to provide care, inappropriate use of resources, or efficiency of care delivered.Examples:
  • Total per capita costs
  • Avoidance of antibiotics for adults with acute bronchitis
  • Episode-based cost measures
Type: CompositeDefinition: A measure that combines several individual measures to produce one result that gives a more complete picture of quality for a specific area or disease.Examples:
  • Comprehensive diabetes care
  • Substance use screening and intervention
  • Optimal vascular care

How do you Determine What to Measure?

Choose measures that:

  • Are relevant to your practice and the population you serve
  • Address perceived or known gaps in care
  • Align with practice goals
  • Align with national or regional initiatives, such as the Merit-based Incentive Payment System (MIPS), Core Quality Measures Collaborative, payers
  • Are important to patients

What are the Components of a Quality Measure?

A measure has several parts, including:

  • Measure ID: Measures can have several different IDs:
  • Denominator: The given population to which a measure applies (i.e., the number of people who should have received an action or service). The denominator is the lower part of a fraction used to calculate a rate. (Example: Women 52-74 years as of December 31 of the measurement year).
  • Numerator: The subset of patients in the denominator for whom a clinical action or service has been provided or for whom a particular outcome has been achieved (i.e., the number of people that actually received an action or service). The numerator is the upper part of a fraction used to calculate a rate. (Example: Women who received a mammogram to screen for breast cancer.)
  • Exclusions/Exceptions: The terms exclusions and exceptions are often used interchangeably, although there are subtle differences. An exclusion is a condition that removes a defined group of patients from the denominator because the measure would not appropriately apply to them. Exceptions depend on clinical judgment and remove patients from both the numerator and denominator. Exceptions are due to medical reasons (e.g., patient is comatose), patient reasons (e.g., patient refuses) and system reasons (e.g., shortage of a vaccine). (Example: Women who had any of the following: bilateral mastectomy; unilateral mastectomy with a bilateral modifier (same claim); two unilateral mastectomies with service dates 14 days or more apart; history of bilateral mastectomy).
  • Measurement Period: The timeframe in which the clinical action or outcome of interest may be accomplished. (Example: Women who received one or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year.)
  • Value Sets: The numerical values (codes) and human-readable names (terms), drawn from standard vocabularies such as SNOMED CT®(www.snomed.org), RxNorm(www.nlm.nih.gov), LOINC(loinc.org), CPT(www.ama-assn.org), and ICD-10(www.cdc.gov), which are used to define clinical concepts used in clinical quality measures. Value sets are available through the Value Set Authority Center (VSAC) of the U.S. National Library of Medicine(vsac.nlm.nih.gov).  

Benchmarks

Benchmarking is comparing one's processes and performance metrics to the best performance and practices in the industry. In health care, benchmarks may be set internally or obtained from clinical data registries, payers (such as the CMS MIPS quality benchmarks(www.cms.gov)) and accreditors (such as the National Committee for Quality Assurance [NCQA] Healthcare Effectiveness Data and Information Set [HEDIS](www.ncqa.org) measures for health plans). Benchmarks should be challenging, but achievable to motivate improvement.

The AAFP has a MIPS Measures Reference Guide to assist reviewing and selecting MIPS quality measures.

What Makes a Good Quality Measure?

The NQF measure evaluation criteria align with criteria established by the AAFP. These include:

  • Importance: The extent to which the measure is evidence based, has substantial potential for improvement through intervention, is prevalent and significant enough in the population to justify efforts, and has a substantial impact on patient and/or community health or value.
  • Scientifically Sound (Measurability): The extent to which the measure produces consistent (reliable) and credible (valid) results. The measure should be precisely defined and specified, easily interpreted, and risk-adjusted as appropriate.
  • Feasibility (Achievability): The extent to which data required is readily available or could be captured without undue burden and at a reasonable cost, and the measure implemented for improvement in the setting at which it is being applied.

Additionally, measures should be evaluated for:

  • Usability: The extent to which the measure results can be used for both accountability and performance improvement.
  • Measures Alignment: Similar and competing measures should be compared and harmonized with the best measure retained and duplicate measures removed. The AAFP advocates for the alignment of quality measures through the Core Quality Measures Collaborative.

How are Quality Measures Developed?

Quality measures are typically developed based on evidence generated through research and clinical practice, with most measures beginning as clinical guidelines. Developers of measures include:

  • Public agencies (e.g., the CMS and the Agency for Healthcare Research and Quality [AHRQ])
  • Private nonprofits (e.g., the National Committee for Quality Assurance [NCQA] and the Joint Commission)
  • Professional medical associations
  • Private groups

The organization that develops and is responsible for updating and maintaining a measure is called a measure steward.

The process of measure development is lengthy and expensive, and requires review of evidence, analysis of care gaps, feasibility assessment, determination of data sources, development of detailed specifications, and field testing.  

How are Quality Measures Endorsed?

The NQF(www.qualityforum.org) is a nonprofit, nonpartisan, membership-based organization which brings together public and private-sector organizations to reach consensus on how to measure quality in health care. NQF does not develop measures, but instead reviews, endorses, and recommends use of measures for various programs. NQF endorsement is voluntary, but endorsed measures are favored for use in federal and private-sector programs because of the rigorous process followed for endorsement.

The NQF uses a Consensus Development Process (CDP) to evaluate and endorse measures. For each topic, expert committees are formed, comprised of patients, physicians, other health professionals, suppliers, subject matter experts, and payers. The committee evaluates measures submitted by developers, issues a draft report of findings, gathers member and public comment, and votes to reach a consensus on endorsement recommendations. Committee recommendations are sent to the Consensus Standards Approval Committee (CSAC) where a final endorsement decision is made.

Serve on a Quality Measures Workgroup

Are you an AAFP member who is interested in serving on quality measures workgroups? Please download and complete the Expression of Interest form and send it to spogones@aafp.org, or contact the Quality Department at (913) 906-6000, ext. 4174.

What is the AAFP’s Role in Measure Development and Endorsement?

The AAFP does not itself develop measures, but advises developers and stakeholders to ensure the voice of family medicine is heard. The AAFP nominates its members as representatives to external workgroups that develop and endorse measures and responds during measure comment periods. The AAFP is represented on the NQF Measures Application Partnerships (MAP), which makes recommendations to CMS regarding measures that should be adopted for use in various payment and recognition programs, such as MIPS, Alternative Payment Models (APMs), Medicaid, and others.  


Reference

1. Centers for Medicare & Medicaid Services. Quality measures.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html(www.cms.gov). Accessed February 7, 2018.