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Making Measurement Meaningful
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Making Measurement Meaningful

Christine K. Cassel, MD, President and CEO, National Quality Forum
A discussion on meaningful measurement and driving greater value in healthcare, and the role of the National Quality Forum.
These are exciting times as the nation progresses toward improved health and healthcare at a lower cost. In January, the US Health and Human Services Secretary made a historic announcement that the department had set a goal to tie 90% of traditional Medicare payments to quality or value by 2019. In March, the Administration launched a public-private network to accelerate the movement toward paying healthcare providers for value rather than volume; and in April, Congress passed bipartisan legislation to reform how physicians are paid by Medicare and establish a new payment formula that pays physicians based on performance. Health plans are similarly promoting value through new incentive structures and delivery system models, and private healthcare delivery systems are redesigning their processes to be more effective and efficient. What ties all of these efforts together is their need for standardized, evidence-based measures, as you cannot improve what you do not measure, and because you need measures to assess the relative performance of clinicians, hospitals, and other providers. 

Reflecting on the Evolution of Measurement
The nation’s ability to gauge quality healthcare has grown over time. Indeed, we’ve seen successes in targeted clinical areas and processes, such as reductions in bloodstream infections and door-to-balloon times for PCI, for example.
These successes did not occur overnight. The National Quality Forum (NQF) was founded in 1999 to identify standardized healthcare quality measures, with the goal of providing more information to the public about the quality and value of different providers. At the time, the thinking was that consumers and purchasers would use this information to select providers, thereby rewarding high quality through increased market share for those clinicians and organizations. While public reporting has led to some important improvements, it hasn’t been the driving force for quality improvement that we envisioned. 
One major change in the past 15 years has been the rising use of quality metrics in payment. The founding strategic documents for NQF focused on public reporting, while today, the emphasis of public and private payers has been on linking quality and value to payment.

Given the increasing uses of measures, the need has grown for accurate, reliable, and meaningful measures. At the same time, it has never been more important to address challenges with current metrics of healthcare performance, from ensuring that measures are capturing meaningful clinical concepts, to reducing measurement fatigue, to getting more performance out of performance measurement.
Moving Toward Alignment
Over the past 15 years, hundreds of quality measures—many endorsed by NQF—have been developed to help providers and purchasers assess their performance, but the enthusiasm to create measures to assess quality, cost, and patient centeredness has placed the burden of measurement on providers. Today, there are simply too many measures in use, overwhelming many
clinicians and prompting a movement to reduce and align measures in both the private and public sectors. The imperative for alignment was emphasized by a long-awaited report released by the Institute of Medicine (IOM) in April, entitled Vital Signs: Core Metrics for Health and Health Care Progress.1 The IOM underscored the growing concerns about measurement strain on providers, the inconsistency of thousands of measures in use, and consumers’ need for transparent and comparable data to make informed healthcare decisions. 
For NQF’s part, we are committed to addressing measure fatigue. Since 2012, NQF’s Measure Applications Partnership, through its recommendations to HHS, has helped to dramatically reduce the number of measures used in some 20 different federal healthcare programs that require measurement and reporting. As an example, after NQF identified the best standard to describe hypertension in a quality metric, CMS reduced 36 different measures of hypertension in use across federal agencies to just 1 recommended measure. NQF hopes to contribute to this success in the private sector through an effort led by America’s Health Insurance Plans in collaboration with CMS on a project that brings together 20 of the nation’s major health insurers, physician specialty groups, and eventually consumers and purchasers to agree upon a core set of measures across clinical specialties.

Charting the Future of Measurement
Beyond alignment, there are pressing technical issues in measurement, including understanding how a particular clinician’s actions affect the health of a patient or ensuring that measures provide accurate, comparable information about different providers.

A notable example is risk adjustment for socioeconomic status (SES) and other demographic factors in quality metrics. This is a controversial issue. Some argue that providers should not be penalized for serving poor, homeless, or safety net populations (which may cause providers to avoid serving such patients), and others argue that such patients should not receive poorer quality
care. To deeply examine this issue, and to start to build consensus about how to move forward, NQF conducted an in-depth study looking at all sides of this issue, including the difficult technical aspects. The panel released a nuanced recommendation for when risk adjustment should be used, and a 2-year trial is now under way to evaluate the merit of changing NQF’s policy to allow
for adjusting certain measures for SES and other demographic factors.

We are also working to help providers, purchasers, and patients assess value. The intersection of cost and quality has been increasingly scrutinized since the release of the IOM’s September 2012 report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America,2 which noted that about one-third of health spending is wasted on unnecessary services, fraud, and other problems. In light of these findings, ever-rising costs, and the laser-sharp focus on value-based payments likely to continue for the foreseeable future, determining a means to assess value is essential for the future of our nation’s health and healthcare. 
Coupled with quality measures, an NQF-endorsed measurement approach—HealthPartners’ Total Cost of Care—considers both the cost of care provided to a patient and the resources used in providing that care. The measure accounts for costs both in and out of the hospital setting, from surgical procedures to pharmacy services and durable medical equipment.
We can’t do this important work alone. Greater collaboration with users and developers of measures—such as our work with HealthPartners—will be essential to making measures more meaningful. In addition, feedback loops from the field, such as those that are being developed with the SES trial, are also essential to helping us understand what’s working and what’s not in practice.

Author Affiliations: National Quality Forum, Washington, DC. 
Source of Funding: None.

Author Disclosures: Dr Cassel reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and supervision.
Address correspondence to: Christine K. Cassel, MD, National Quality Forum, 1030 15th St, NW, Ste 800, Washington, DC 20005. Tel: 202-783-1300. E-mail:
1. Institute of Medicine. Vital signs: core metrics for health and health care progress. Washington, DC: The National Academies Press; 2015. Accessed May 2015.
2. Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. Washington, DC: The National Academies Press; 2012. Accessed May 2015.
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