Quality Measurement

Quality Measurement and Persons with Disabilities: An AAHD Area of Focus

The American Association on Health and Disability is regularly and actively directly involved in health and related “quality” measurement, that impacts and affects persons with disabilities.

Defining Health Care Quality

The National Academy of Medicine defines health care quality as:

“Quality is the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

CMS “Meaningful Measures” and the CMS “Universal Foundation”

CMS launched in 2023 the “CMS Universal Foundation To Align Quality Measures,” an effort to increase alignment across CMS’s more than 20 quality programs using over 500 quality measures. Using the eight CMS National Quality Strategy Goals, the CMS Universal Foundation builds on the 2021-2022 CMS “Meaningful Measures” initiative. (Michelle Schreiber, Director, Quality Measurement and Value-Based Incentives Group, CMS: presentation slides to the July 14, 2023 NCQA webinar – “The CMS Universal Foundation To Align Quality Measures.”)

Quality Measurement and Medicaid

CMS has announced mandatory Medicaid and CHIP “Core” Quality Measures (CMS, Federal Register, August 31, 2023, “Medicaid Program and CHIP: Mandatory Medicaid and CHIP Core Set Reporting;” and, CMS SHO #23-005, December 1, 2023, “Initial Core Set Mandatory Reporting Guidance.”)

There are 33 adult measures, 10 being behavioral health. There are 27 child measures, 7 being behavioral health.” 

Quality measures are also included in the CMS/CMMI ACA authorized Medicaid “Health Homes” program.

Quality Measurement and Medicare

CMS quality measures are included in the Medicare Advantage Plan and Medicare Part D Quality Stars Rating System; Medicare Shared Savings Program Quality Measures (and Accountable Care Organizations); Special-Needs Plans for persons dually eligible for Medicare and Medicaid [D-SNAPs include PACE Plans]; and CMS MMCO Financial Alignment Demonstrations for Persons Dually Eligible for Medicare and Medicaid. (CMS, Federal Register, November 16, 2023: “Medicare and Medicaid Programs: CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes To Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program.”)

ACA Marketplace Plans: Quality Measurement

Quality measures are included in ACA Marketplace plans. (CMS, “Health Insurance Marketplace Quality Indicators,” October 24, 2023 summary of the Marketplace Quality Rating 5 Star Rating System and the Qualified Health Plan Enrollee Experience Survey.)

HEDIS (Healthcare Effectiveness and Data Information Set) (NCQA) – Use by Medicaid, Medicare, and Marketplace

HEDIS is used in Health Plan Accreditation, quality ratings programs (e.g., NCQA’s Health Plan Ratings, QRS, Star Ratings) and regulatory compliance across CMS programs. HEDIS measures make up the majority of measures in the Quality Rating System and Medicaid core sets, and represent a sizeable portion of measures in the MA Star Ratings program (full breakdown below). Star Ratings can be used by consumers to compare plans and can impact plans financially with performance-based incentive payments.

HEDIS measures represent:

26 of the 37 QRS (Marketplace/Exchange) measures

20 of the 33 Medicaid Adult Core Set measures

17 of the 27 Medicaid Child Core Set measures

14 of the 40 MA Stars measures

[NCQA staff summary shared with AAHD Clarke Ross, December 13, 2023.]

CAHPS (Consumer Assessment of Healthcare Providers and Systems) (AHRQ) – Use by Medicaid, Medicare, and Marketplace

“CAHPS surveys are an integral part of CMS’ efforts to improve healthcare in the U.S….Instead of only paying for the number of services provided, CMS also pays for providing high quality services. The quality of services is measured clinically, administratively, and through the use of patient experience of care surveys.”

CAHPS surveys are used in hospitals; home health; home-and-community-based services (HCBS); fee-for-service payment; Medicare Advantage and Prescription Drug Plans; In-Center Hemodialysis; Medicaid adult quality measures; hospice; outpatient and ambulatory surgery; Merit-Based Incentive Payment Systems (MIPS); and emergency departments. [CMS website; “Consumer Assessment of Healthcare Providers and Systems (CAHPS;” December 18, 2023]

Medicaid Home-and-Community-Based Services (HCBS)

CMS has announced quality measures in the Medicaid HCBS program. [CMS, SMD #22-003, July 21, 2022, “Home-and-Community-Based Services Quality Measure Set,” and CMS, March 7, 2023, “Home-and-Community-Based Services Quality Measure Set Measure Summaries and License Agreements.”]

CMS Contracts with Private Organizations for Quality Measurement Analysis, Sorting, and Recommendations

CMS currently contracts for quality measurement analysis, sorting, and recommendations, including with:

Acumen

Batelle Memorial Institute – see below

Core Quality Measures Collaborative (CQMC), administered by America’s Health Insurance Plans, AHIP)] [AAHD is a CQMC member]

Lewin

Mathematica – Mathematica administers the CMS Medicaid and CHIP Core Quality Measures program.

Other Quality Measures Organizational Efforts

ACL finances: Shirley Ryan Ability Lab RRTC on HCBS; University of MN Institute on Community Integration; Brandeis University Community Living Policy Center; HSRI National Center Advancing Person Centered Practices and Systems (NCAPPS); ADvancing States, NASDDDS, and HSRI National Core Indicators; US Aging administered Aging and Disability Business Institute work on health plan-CBOs (community-based organizations) partnerships that includes quality measures.

AHRQ operates the CAHPS program.

AHRQ CAHPS includes the Home-and-Community-Based Services program.

AHRQ contracts with the Yale University CORE program for CAHPS.

AHRQ contracts with Truven Health Analytics for Environmental Measure Scans, including HCBS.

HRSA requires quality measures for federally quality health centers (FQHCs).

SAMHSA requires quality measures for Certified Community Behavioral Health Centers (CCBHCs).

Council on Quality and Leadership (CQL) Personal Outcome Measures (POM).

NCQA (National Committee for Quality Assurance

AAHD’s Clarke Ross is a member of the NCQA National Consumers Advisory Council and an advisor to the NCQA Health Equity Workgroup. See HEDIS, above.

Battelle and the National Quality Forum (NQF)

In February 2023, CMS reassigned the Measure Application Partnership (MAP) project from NQF to Battelle, the CMS Measure Management System (MMS) contractor. Battelle administers the Partnership for Quality Measurement (PQM).

[Between 2011-March 24, 2023: CMS contracted with the NQF to administer the MAP (Measure Application Partnership) program. AAHD’s Clarke Ross served on various MAP committees, since 2012, including most recently the MAP coordinating committee. Several years ago, CMS reassigned the Medicaid and CHIP “core” measures project from NQF to Mathematica.

AAHD Quality Priorities

The American Association on Health and Disability works through the Consortium for Constituents with Disabilities (CCD) Task Force on LTSS (long-term services and supports), and Disability and Aging Collaborative (DAC) on quality measurement issues. Our areas of focus include:

1. Home-and-Community-Based Services and Supports (HCBS).
2. “Patient/Participant Reported Outcomes (PROs) – PRO Quality Measures (PRO-QMs).
3. Special Needs Plans (SNP) Coalition on Medicare Health Outcomes Survey (HOS).
4. Integrated behavioral health-primary care-and general health efforts including the No Health without Mental Health and partners work.
5. CQMC (above) Behavioral Health Committee.
6. CQMC (above) ACO/PCMH/Primary Care Committee.
7. American Board of Family Medicine (ABFM) efforts in Primary Care.
8. Efforts to link primary care with behavioral health, with LTSS, and with Medicaid HCBS.
9. AAHD advocates existing Measure Sets: (a) National Core Indicators; (b)Personal Outcome Measures; and (c) CAHPS-HCBS Experience Survey.
10. AAHD also monitors and attempts to apply clinical quality measures to persons with disabilities. CMS defines a clinical quality measure as “a tool that quantifies healthcare processes, outcomes, patient perceptions, and organizational structures and/or systems associated with the ability to provide high-quality health care and/or that relate to one of more quality goals for health care; and, is supported by the evidence.

AAHD Quality Measures Advocacy Submissions

Available here are:

1. AAHD and the Lakeshore Foundation October 10, 2023 to NCQA Consumer Advisory Council: PDF
2. AAHD and the Lakeshore Foundation May 2, 2023 to NCQA Consumer Advisory Council and Public Sector Advisory Council: PDF
3. AAHD and the Lakeshore Foundation April 17, 2023 to NCQA Behavioral Health Quality Framework: PDF

Quality Measurement Gaps – AAHD/Lakeshore To NCQA

AAHD and the Lakeshore Foundation submitted issues of priorities to the February 22 National Committee on Quality Assurance (NCQA) Consumer Advisory Council (CAC) meeting.  Available here is the AAHD-Lakeshore outline.

The submission includes a number of quality measures not yet accepted by CMS and its contractors. Available here are the measures:

1. Community-Based Mental Health After Hospitalization – Battelle PQM – February 2024.
2. Discharge From Inpatient To Home-Based Settings – Lewin for CMS – May 2023.
3. Sharing LTSS Plan with Primary Care – Mathematica Core for CMSe-MathematicaCore-April-and-July2022 – April and July 2022.
4. Social Needs Screening and Intervention – Mathematica Core for CMS – February 2024.
5. ABFM Primary Care – Continuity-PROs-Comprehensiveness – February 20 2024 web site posting.

Follow-up After Hospitalization for Mental Illness – Quality Measure Accountability