Quality measures in health care: Metrics and best practices

Quality and performance measures take many forms and have implications for the health of your community and, often, your compensation. There’s a lot that goes into making, applying and meeting these measures. Knowing the basics and having strategies for implementation will give you a big step up.

Quality measures are tools that quantify and inform us how the health care system is performing. Quality measures help identify weaknesses, prioritize opportunities and can be used to identify what works and doesn’t work to drive improvement. Measures are used for quality improvement, benchmarking and accountability.

The primary purpose of quality measurement should be to identify opportunities to improve patient care. Measures can prevent the overuse, underuse and misuse of health care services and can identify disparities in care delivery and outcomes.

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:

Measure development is a three- to eight-year process that often costs around $1 million per measure. Once developed, adoption and use of a measure can take another two to five years.

Clinical quality measures vs. performance measures

Quality measures and performance measures can sometimes be the same measure, but they have different internal and external uses:

• Quality measures are intended for use within a medical clinic or organization to drive quality improvement efforts and are not tied to payment incentives or penalties.
• Performance measures are intended for use with payers and are often tied to payment incentives and penalties.

Both 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.

CMS is a major developer of quality measures. The CMS measure inventory houses over 500 measures designed to meet demands for performance data, promote quality and improve decision-making.

Each CMS quality measure is defined by a handful of selected metrics, including:

• 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.)
• 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).
• Denominator exclusions: 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).

CMS is most interested in outcomes-based measurements, but there are several types of measurements, including:

Capturing the complex and comprehensive nature of family medicine is challenging in a system of quality measures built to focus on specific tasks and disparate patient conditions.

Quality measures that are designed for primary care by primary care physicians, like the Person-Centered Primary Care Measure, are collected by the Center for Professionalism and Value in Health Care.

Common traits of these measures include a focus on patient experiences and outcomes, administrative burden reduction, and an understanding of the unique qualities of family medicine to improve health and lower costs.

Most of the time, the measures payers include in their contracts with physicians dictate which measures a clinic focuses on. Therefore, it's important to understand all the measures that are included in your contracts with payers.

Strategies that can help you maximize your performance on measures and improve patient outcomes include:

The AAFP does not develop measures, but advises developers and stakeholders to ensure the voice of family medicine is heard and develops tools that can help family physicians navigate measurements.

Quality measures advocacy

AAFP member representatives serve on more than 40 external quality measures committees, including the:

• Partnership for Quality Measurement
• Core Quality Measures Collaborative
• American Board of Family Medicine
• Centers for Medicare and Medicaid Services
• National Quality Forum

Policies that guide AAFP federal advocacy for simple, primary care–centered policy measures are:

• Performance measures criteria
• Performance measures in value-based payment models for primary care