1. Building High Value
Health Systems:
The Role of
Performance
Measurement

2. Presentation at a Glance
 Role of the National Quality Forum in the Performance
Measurement Enterprise
 National Priorities and Strategies to Achieve Value
 Measurement Framework and Portfolio Focused on Value
 Accountability Programs that Encourage and Reward HVHSs
2

3. Role of the National Quality Forum
 Private, non profit established in 1999
▫ Non-partisan; Washington, DC based
 Mission is to improve the performance of the nation’s healthcare
system
 Supported by public dollars, membership dues and private
foundations
 Board and 450 plus members includes varied stakeholders
3

4. Roles of the National Quality Forum
 Private sector standard setting organization
▫ National Technology Transfer and Advancement Act
▫ Measures, serious reportable events, best practices
 Neutral convener
▫ National Priorities Partnership (NPP) and Measure Applications
Partnership (MAP)
▫ Multi-stakeholder
▫ Public-private sector
▫ Serve in advisory capacity to HHS and others
4

5. Value Agenda Strategy
Accreditation Health IT Value-based Public
& Certification Incentives Payment Reporting
Prioritize Measure Improve
Accountability
Programs
National Quality Standardized
&
Strategy Measures
HVHS Improvement
Efforts
Infrastructure Support
Electronic Data Platform
Quality Data Model
Measure Authoring Tool
5

6. Presentation at a Glance
 Role of the National Quality Forum in the Performance
Measurement Enterprise
 National Priorities and Strategies to Achieve Value
 Measurement Framework and Portfolio Focused on Value
 Accountability Programs that Encourage and Reward HVHSs
6

7. National Quality Strategy
Statutory Authority
 Health reform legislation, the Affordable Care Act (ACA),
requires the Secretary of Health and Human Services to
“establish a national strategy to improve the delivery of
healthcare services, patient health outcomes, and population
health.”
▫ HR 3590 3011, amending the Public Health Service Act (PHSA) by adding
399HH (a)(1)
7

8. ACA: A Framework & Resources for
Measurement-Based Improvement
 HHS must develop a National Quality Strategy (NQS) to make
care safe, effective and affordable
 NQS to be shaped – and specified – with input from diverse
healthcare leaders in the field of health and healthcare
 Coordination and alignment within the Federal government and
across the public and private sectors is key to the ultimate
success of the NQS in transforming the US healthcare system
8

9. National Priorities Partnership:
Provides Input to HHS
 Convened by the NQF – viewed as objective, neutral and experienced in building
consensus
 51 leaders across every key health and healthcare sector
▫ Consumers
▫ Purchasers
▫ Quality alliances
▫ Health professionals/providers
▫ State-based associations
▫ Community collaboratives & regional alliances
▫ Accreditation/certification groups
▫ Health plans
▫ Industry
▫ Federal agencies (AHRQ, CDC, CMS, FDA, HRSA, NIH, OMH, SAMHSA, VA)
 Co-Chairs
▫ Bernie Rosof, Physician Consortium for Performance Improvement
▫ Helen Darling, National Business Group on Health
© National Priorities Partnership
9

10. National Priorities Partnership Responsibilities
 October 2010: NPP provides input to HHS to inform the
development of the NQS
 March 2011: HHS issues NQS based on the triple aim
 September 2011: NPP input to HHS helps to make NQS more
actionable:
▫ Identification of goals and measures
▫ Recommendation of strategic opportunities
▫ Consensus across key leaders about where they should drive
their organizations
© National Priorities Partnership
10

11. HHS’s National Quality Strategy Aims
and Priorities
© National Priorities Partnership
11

12. NPP INPUT ON HHS’S NATIONAL PRIORITIES:
Prevention and Treatment of Cardiovascular Disease
Goals:
Promote cardiovascular health through:
 Community interventions (e.g, access to healthy food
and recreational facilities
 Adoption of healthy lifestyle behaviors (e.g., tobacco
cessation)
 Delivery of clinical preventive services (e.g., to
achieve blood pressure and cholesterol control)
Measure Concepts:
 Access to healthy foods  Consumption of calories from fats
 Access to recreational facilities and sugars
 Tobacco use by adults and  Control of high blood pressure
adolescents  Control of high cholesterol
12

13. Measurement Cascade of National Priority
13

14. NPP Report:
Three Sets of Strategies
 One: A national strategy for data collection, measurement and
reporting that supports measurement-based improvement so we
know “how we are doing” against the NQS
 Two: Payment and delivery system reform—emphasizing
primary care—that rewards value over volume and promotes
patient-centered outcomes, efficiency, and appropriate care
while reducing waste
 Three: Community infrastructure (public-private) responsible for
improvement efforts, resources for benchmarking and
comparing performance; and mechanisms to identify, share and
evaluate progress
14

15. Presentation at a Glance
 Role of the National Quality Forum in the Performance
Measurement Enterprise
 National Priorities and Strategies to Achieve Value
 Measurement Framework and Portfolio Focused on Value
 Accountability Programs that Encourage and Reward HVHSs
15

16. Portfolio of NQF-Endorsed Measures
 700 Measures in portfolio – all settings, all levels
 Evaluation Criteria
▫ Importance
▫ Scientific Acceptability
▫ Usability
▫ Feasibility
 Constantly Evolving
▫ Raise the bar
▫ Composite measures
▫ Harmonize across sites
 Disparities in all we do
16

17. 2D Framework for Measure Development
 National Quality Strategy Priorities
▫ Population health, prevention, person/family-centered
care, safety, communication/coordination, affordable
care
 Patient Focused Episodes
▫ Top 20 Medicare Conditions
▫ Child Health Conditions
17

18. 2-D Measurement Framework: AMI Episode
Post AMI Trajectory 1 (T1)
Relatively healthy adult
Patient & Family Focus on:
Engagement • Secondary prevention
• Quality of Life
Care Coordination • Functional Status
• Advanced care planning
Population Health
10 Prevention Post Acute/
Acute
Rehabilitation 20 Prevention
Phase
20 Prevention Phase
(CAD with prior AMI)
Post AMI Trajectory 2 (T2)
PHASE 2 PHASE 3 PHASE 4
Adult with multiple co-morbidities
Focus on:
PHASE 1
• Palliative Care
• Functional Status
Living w/ Illness/Disability (T1) • Advanced Care Planning
Staying Healthy Getting Better
Coping w/ End of Life (T2)
Population Health
Overuse
Episode begins – onset of Episode ends – 1
symptoms year post AMI
Safety
18

19. Quality Measurement in Evolution
Patient-level outcomes (better health)
 Morbidity and mortality
 Functional status
 Health-related quality of life
 Patient experience of care
Processes of care (better care)
 Clinical processes tightly linked to outcomes
 Care coordination and transitions
 Patient engagement and alignment with patient preferences
Processes of care (affordable care)
 Per capita cost
 Total cost of care
 Patient out of pocket cost
19

20. Sample Measurement Cascade—Tobacco Use
National National Rates of
Smoking/Tobacco Use
State/Community State Rates of
Smoking/Tobacco Use
Community Rates of
Smoking/Tobacco Use
State Pricing Policies
on Tobacco Products
Health Plan Population
Health Plan Population Health Plan Population Health Plan Beneficiary
Health Plan of Smokers/Tobacco
Users
of Smokers/Tobacco
Users Offered Smoking
of Smokers/Tobacco
Quit Rates
Incentives for Smoking
Cessation
Cessation
Provider-Level Percentage of Percentage of Smoker
Provider Population Rates of
Smokers/Tobacco
Smoker/Tobacco User
Population Offered
Provider-Level Quit
Rates
Referred for
Community-Based
Users Smoking Cessation Smoking Cessation
Clinician/Health Clinician-Level Rates of
Patients Who Are
Percentage of Patients
Who Are Smokers Clinician-Level Quit
Percentage of Smokers
Referred for
Smokers/Tobacco Offered Smoking Rates Community-Based
Professional Users Cessation Smoking Cessation
Percentage of Smokers
Patient/Consumer Who Engage in
Behaviors to Stop
Smoker/Tobacco User
Quit Rates
Smoking

21. 21
21

22. Presentation at a Glance
 Role of the National Quality Forum in the Performance
Measurement Enterprise
 National Priorities and Strategies to Achieve Value
 Measurement Framework and Portfolio Focused on Value
 Accountability Programs that Encourage and Reward HVHSs
22

23. Applying Performance Information
Accountability
Public health/disease Accreditation Performance-
Quality improvement surveillance and regulation based payment Improve
Quality improvement HIT incentive Consumer Care
Certification
with benchmarking payments choice
Transparency
23

24. Organization and Payment:
Selection of Performance Measures

25. Measure Applications Partnership
Statutory Authority
 Health reform legislation, the Affordable Care Act (ACA),
requires HHS to contract with the consensus-based entity (i.e.,
NQF) to “convene multi-stakeholder groups to provide input
on the selection of quality measures” for public reporting,
payment, and other programs.
▫ HR 3590 3014, amending the Social Security Act (PHSA) by
adding 1890(b)(7)
25

26. Measure Applications Partnership
MAP Coordinating Committee Membership
AARP George Isham, MD, MS
chairs
Co-
Academy of Managed Care Pharmacy
AdvaMed Elizabeth McGlynn, PhD, MPP
AFL-CIO Richard Antonelli, MD, MS
Subject Matter
America’s Health Insurance Plans Bobbie Berkowitz, PhD, RN, CNAA, FAAN
Experts
American College of Physicians
Joseph Betancourt, MD, MPH
Organizational Members
American College of Surgeons Ira Moscovice, PhD
American Hospital Association Harold Pincus, MD
American Medical Association Carol Raphael, MPA
American Medical Group Association Agency for Healthcare Research and Quality
Federal Government
American Nurses Association Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Members
Catalyst for Payment Reform
Consumers Union Health Services and Resources Administration
Federation of American Hospitals
LeadingAge Office of Personnel Management/FEHBP
Maine Health Management Coalition Office of the National Coordinator for HIT
National Association of Medicaid Directors
Certification
Accreditatio
American Board of Medical Specialties
National Partnership for Women and Families
Liaisons
National Committee for Quality Assurance
Pacific Business Group on Health
n/
The Joint Commission
26

27. MAP Pre-Rulemaking Input to HHS
Recommendations in three sections:
 Vision for harmonized performance measurement
 Measure selection
▫ Criteria
▫ Measure-by-measure analysis
 Core measures sets
27

28. MAP Measure Selection Criteria
1. Measures meet NQF endorsement criteria
2. Measure set adequately addresses the National Quality
Strategy priorities
3. Measure set adequately addresses high-impact conditions
relevant to the program’s intended population(s) (e.g.,
children, adult non-Medicare, older adults, dual eligible
beneficiaries)
4. Measure set promotes alignment with specific program
attributes (i.e., intended setting(s), level(s) of analysis,
and population(s)
28

29. MAP Measure Selection Criteria
5. Measure set includes appropriate mix of measure types
(i.e., outcome, process, experience of care, cost,
structure)
6. Measure set enables measurement across the patient-
focused episode of care
7. Measure set includes considerations for healthcare
disparities
8. Measure set promotes parsimony
29

30. Pre-Rulemaking Guidance: Process and Timeline
Clinician
List of Measures Workgroup
from HHS for Pre- Meeting
Public
Rulemaking Dec 12
Comment
Analysis
PAC/LTC
Workgroup
Meeting
Dec 14
Coordinating
Coordinating
All MAP Coordinating Committee
Committee Hospital
Workgroups Committee
Workgroup Pre-Rulemaking
Nov 1-2 Meeting
Dec 8 January 5-6 Analysis
Dec 15 In-Person
In-Person
Web Meeting Meeting Final Report
Meeting
Duals February 1
Workgroup
Meeting
Dec 16
30

31. MAP Pre-Rulemaking Approach
Vision
• National Quality Strategy
• Coordinated and accountable care delivery models
• Measurement Tactics
• Cascading measure sets focused on value
• Harmonized measures across settings and populations
Clinician Hospital PAC/LTC
Core = Available Measures + Core = Available Measures + Core = Available Measures +
Gap Concepts Gap Concepts Gap Concepts
MAP Input on HHS Proposed Program Measure Sets
Outpatient ESRD
Hospital Quality Long-Term
PQRS Quality Hospice
EHR Incentive Program VBP Incentive Care
Reporting Care
Program Hospitals
Program
Inpatient Inpatient Skilled
Programs Listed for Quality Cancer Psychiatric
Rehab Home Nursing
Hospitals Hospitals
Illustrative Purposes Reporting Facilities Health Care Facilities
Program
Coordinated Delivery Programs (ACOs)
31

32. Aligning Accountability Programs with Value:
The Performance Measurement Enterprise
Electronic Alignment of Evaluation
Priorities and Standardized
Data Environmental and
Strategies Measures
Platform Drivers Feedback
National Quality NQF Endorsement Quality Data Model Measures Applications Measure Use
Strategy Process Partnership
Measure Authoring Impact on
National Tool Quality Positioning Health, Health
Priorities System Care, and Cost
Partnership
High Impact
Conditions
32

33. In summary, we all must align efforts to
drive change
…focus on the same set of priorities and goals laid out in the NQS…with
public and private sectors rowing in the same direction, at the same time,
for shared and important gains in improving health.
…recognize that the key to health and well-being begins long before an
individual enters the healthcare system and collaborate within communities
to accelerate progress on healthy behaviors and social determinants as
contributors to health.
…use the same data platforms, measures, and public reporting of
performance .
…send unified signals to the market about incentives and rewards.
…take great strides to find places where both public and private sectors can
make gains individually and in partnership removing unnecessary and
burdensome fragmentation and complexity.
33