Vital Signs: Core Metrics for Health and Health Care Progress (2015)

6

Action Agenda

The nation needs a set of core health and health care measures that also embodies its vision and can be used to gauge its progress. This chapter presents a summary of the Committee’s findings, conclusions, and recommendations, along with a brief overview of the conditions important to making a core measure set a reality. Because this process will require broad leadership from stakeholders throughout the nation, the Committee’s recommendations are targeted to the various stakeholders’ opportunities and responsibilities. Given the interdependence of these opportunities and responsibilities, as well as the health system’s complexity, no single sector acting alone can bring about the transformative change needed to align and focus the measurement enterprise. Each sector faces different measurement challenges, has different roles and opportunities, is accountable for different aspects of the system’s progress, and depends on critical preconditions for success.

FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS

Based on the findings and conclusions identified throughout the preceding chapters, the Committee recommends the rapid and effective adoption and implementation of the core measures for better health at lower cost identified in this report (see Figure 6-1). It further recommends the specific actions for different groups summarized in Box 6-1 and detailed in the subsections that follow.

FIGURE 6-1 The core measure set.

The Nation

Findings: The complexity of health and health care—causally, clinically, therapeutically, and organizationally—presents myriad challenges to health improvement strategies, as well to the measurement of progress. The result is a sometimes confusing and burdensome array of measures that focus on processes of care and diffuse measurement efforts. Although health and health care pose distinctive requirements, the challenge of simplifying and targeting measures has been faced successfully in other sectors through standardized reporting on a relatively few issues.

Conclusions: A parsimonious and standardized set of core measures aimed substantially at outcomes could improve the ability of both decision makers and the public to direct their attention and understanding to the most important issues in health and health care. Several such issues—for example, the influence of behavioral, social, and environmental factors—will require particular attention in the refinement and application of measurement tools.

Recommendation 1: The parsimonious set of measures identified by the Committee should be widely adopted for assessing the state of America’s health and health care and the nation’s progress toward the goal of better health at lower cost.

All People—as Individuals, Family Members, Neighbors, Citizens, and Leaders

Findings: All people have a strong stake in the issues articulated by the core measure set, and there is growing appreciation of the potential health yield from personal engagement. Yet that potential often goes unrecognized among the many factors in play. A stable, reliable set of key issues to which awareness, attention, and action can be directed is currently lacking.

Conclusions: A core measure set is needed to enable better-informed, more active patient and public leadership for progress in health by providing a common set of reference points and a higher level of transparency on system performance.

Recommendation 2: All people should work to understand and use the core measure set to assist in taking an active role in shaping their own health prospects and those of their families, their communities, and the nation.

The Federal Government

Findings: Many areas of redundancy and overlap in health data and reporting requirements exist within current federal health programs. The result is inefficiencies both internally for the U.S. Department of Health and Human Services (HHS) and externally in its work with providers and other stakeholder groups. In turn, this inefficiency may lead to unnecessary burdens when the collection and management of redundant measures imposes associated costs that outweigh the benefits, as well as to lost opportunities when the data collected are neither working synergistically with those collected in other programs nor directed optimally toward the development of new knowledge.

Conclusions: Use of a core measure set throughout all federal health programs could help better orient those programs while expanding the reach of their contributions. Standardization and coordination are needed among federal health measurement programs to ensure a consistent focus on the outcomes that matter most.

Recommendation 3: With the engagement and involvement of the Executive Office of the President, the Secretary of the U.S. Department

of Health and Human Services (HHS) should use the core measure set to sharpen the focus and consistency and reduce the number and the burden of measure reporting requirements in the programs administered throughout HHS, as well as throughout the nation. To this end, the Secretary should incorporate the standardized core measure set into federally administered programs, concomitantly eliminating measures for which the basic practical issues are engaged by the core set.

• HHS’s national agenda frameworks for health, including the National Quality Strategy and the National Prevention Agenda;
• the Meaningful Use Program, administered by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator (ONC), to ensure that the core measure set becomes a central element of every electronic health record;
• CMS’s accountable care organization measurement and reporting requirements;
• CMS’s strategies for promoting quality improvement and innovation in health care financing and delivery through the work of the Center for Medicare & Medicaid Innovation;
• federal health care reporting requirements;
• streamlined reporting requirements under state Medicaid waiver authority; and
• categorical health grant program management.

Findings: Successful implementation of the core measure set will depend on leadership that effectively identifies priorities, thereby motivating action and enabling key stakeholders to work collaboratively. Practical tools that can facilitate focus among multiple stakeholders on the issues that matter most to the health of the nation are currently lacking.

Conclusions: Visible national leadership is needed for the successful adoption and use of core measures that emphasize what matters most. The effectiveness of the core measures in unlocking the benefits of enhanced comparability and reduced measurement burden will depend on how broadly and completely the set is implemented.

Recommendation 4: With the engagement and involvement of the Executive Office of the President, the Secretary of the U.S. Department of Health and Human Services should develop and implement a strategy for working with other federal and state agencies and national organizations to facilitate the use and application of the core measure set. This strategy should encompass working with

• the Secretary of the U.S. Department of the Treasury on use of the core measure set by tax-exempt hospitals and health systems in demonstrating their community benefit contributions;
• other cabinet departments in administration of their health-related activities—for example, in social services, the environment, housing, education, transportation, nutrition, and parks and recreation;
• state and local governments and voluntary organizations in adapting use of the core measures to their needs and circumstances; and
• multiple stakeholders through the Center for Medicare & Medicaid Innovation in piloting implementation of the core measures through multilevel stakeholder initiatives.

Findings: Despite coordinating projects and programs, efforts to develop and implement measures for the U.S. health system remain fragmented and too often unproductive, with different groups at different levels taking different approaches to assessment and reporting. Progress in health will depend on aligned work by a broad range of stakeholder groups, whose collective efforts currently lack the necessary guidance that could be provided by a standardized core measure set.

Conclusions: A practical, parsimonious, meaningful core measure set that is relevant to the common agendas of different groups is needed to accelerate system-wide progress in health and health care. The Committee has proposed the necessary core measure foci and identified the best current measures, but in many cases, significant measure development and standardization are needed, and these efforts will require the involvement of multiple stakeholder organizations.

Recommendation 5: The Secretary of the U.S. Department of Health and Human Services should establish and implement a mechanism for involving multiple expert stakeholder organizations in efforts to develop as necessary, maintain, and improve each of the core measures and the core measure set as a whole over time. The Secretary’s role should encompass stewardship of work on

• national standardization of the best current measures and related priority measures detailed in this report;
• development of the longer-term indicators necessary to improve the utility and generalizability of the core measures;
• national standardization of reporting on health disparities for each of the core measures, including disparities based on race, ethnicity, gender, and socioeconomic status;

• periodic review and revision of the individual measures in response to changing circumstances; and
• periodic review and revision of the core measure set in response to changing circumstances.

The Committee recommends that the Secretary have in place by 2016 a national plan for sustained application, monitoring, evaluation, and improvement of the core measure set.

The sample schematic presented in Figure 5-2 presents some of the likely elements needed in stewarding the implementation of core metrics from “Core Metrics 1.0,” as represented in this report by the best current measures and current national performance numbers, to “Core Metrics 2.0,” which will incorporate new, pilot-tested composites and will be informed by a multi-stakeholder process of achieving deep standardization of measure specifications at multiple levels.

Governors, Mayors, and Health Leaders

Findings: Data on health and health care in different states, counties, and regions often are insufficient for direct comparison on some of the most critical factors shaping the health of the population. The absence of reliable guideposts on the status of important preconditions for progress can result in delays and missed opportunities for learning, sharing best practices, and motivating action. Similarly, without comparable information from the state, county, and community levels, the ability of health stakeholders at these levels to work in a strategically coordinated fashion is fundamentally impaired.

Conclusions: Current understanding of the relative performance of the health system is limited by a lack of standardized measures and data that enable direct comparisons among states, communities, and institutions. A common set of reference points for assessing progress could enable shared focus and accountability and enhance coordination and engagement among key stakeholders with responsibility for health and health care at the community, county, and state levels.

Recommendation 6: Governors, mayors, and state and local health leaders should use the core measure set to develop tailored dashboards and drive a focus on outcomes in the programs administered in their jurisdictions, and they should enlist leaders from other sectors in these efforts.

Clinicians and Health Care Delivery Organizations

Findings: The number of quality measures that health care providers are required to report has increased significantly and imposes a burden on clinicians and health care organizations that is disproportionate to their potential benefit. Focus and streamlining of health measurement are needed to ensure that clinicians and health care delivery organizations have access to high-quality information with the least possible burden in terms of time and cost. A more focused measurement system could reduce formal reporting responsibilities and provide more local discretion on which non-core measures are most useful and important. Clinicians generate much of the data necessary for measurement, must translate measures into action for improvement, and can benefit directly from enhanced efficiency and effectiveness of measurement.

Conclusions: The active participation of clinicians and health care organizations is essential to remedy this situation and achieve the potential of a core measure set. Clinicians and health care organizations need to recognize the role of the core measures in improving care for individual patients and the health care enterprise.

Recommendation 7: Clinicians and the health care organizations in which they work should routinely assess their contributions to performance on the core measures and identify opportunities to work collaboratively with community and public health stakeholders to realize improvements in population health.

Employers and Other Community Leaders

Findings: The health of a population depends on actions in multiple settings and sectors. Therefore, improvement in health depends on effective leadership on the part of multiple stakeholders, including employers, schools, utilities, law enforcement, and others. Core measures can act as a tool that enables employers and other community leaders to identify gaps or shortfalls in the health of the population of concern and identify the services most important to their constituents, and that facilitates coordination among those involved in effecting change. In the case of employers, core measures also can serve as a tool for decision making regarding the allocation of health and health care resources to optimize the health of their employees.

Conclusions: Accountability for the health of any population or community is shared among a range of stakeholders. Providing individuals with reliable measures through which to understand personal and community health can enable more active participation and influence by employers and

other community leaders with respect to the decisions—both individual and collective—that impact health outcomes.

Recommendation 8: Employers and other community leaders should use the core measures to shape, guide, and assess their incentive programs, their purchasing decisions, and their own health care interventions, including initiatives aimed at transparency in health costs and outcomes and at fostering seamless interfaces between clinical care and supportive community resources.

Payers and Purchasers

Findings: The rising costs of care present a challenge for payers, purchasers, and the nation. This growing concern has led to a proliferation of requirements for data collection and reporting, as well as various approaches to accountability based on measurement. However, the success of efforts to assess and compare quality, efficiency, and other provider-specific factors has been limited by the absence of comparable standardized measures on which to base reliable conclusions.

Conclusions: Effective accountability depends on effective measures that target the results that matter most and act as accessible tools for making choices and changes in decisions about care. Core measures have the potential to act as a tool for more accurate, meaningful decision making for payers and purchasers by parsimoniously information on and enabling comparisons of health and health care performance for different populations or groups. To this end, harmonization is needed to ensure that reporting requirements are anchored in the issues that matter most and are implemented efficiently so as to provide the information needed by payers and purchasers.

Recommendation 9: Payers and purchasers of health care should use the core measures to capture data that can be used for accountability for results that matter most to personal and population health, to refine the analytics involved, and to make databases of the measures available for continuous improvement.

Standards Organizations

Findings: The proliferation of measures and reporting requirements is due in part to the expansion of measure development and implementation by standards organizations that encourage or require providers to report on performance for accreditation purposes. Despite some important advances in quality, the aggregate impact of the wide range of measures employed by

standards organizations remains uncertain. A lack of transparency due to proprietary data and measures limits the capacity to assess relative health outcomes and health care performance.

Conclusions: Support for core measures by standards organizations can enable efficiency and focus in measurement and monitoring of the impact of performance standards in the health system. Indeed, core measures are necessary for drawing reliable conclusions about standards and interventions that matter most in improving health and health care.

Recommendation 10: Measure developers, endorsers, and accreditors, such as the National Quality Forum (NQF), the National Committee for Quality Assurance (NCQA), and the Joint Commission, should consider how they can orient their work to reinforce the aims and purposes of the core measure set, and they should work with the Secretary of the U.S. Department of Health and Human Services in refining the expression and application of the core measure set nationally.

CRITICAL FACTORS FOR SUCCESS

Leadership

Leadership is critical to the success of any endeavor. Because the stakeholders and organizations involved in health and health care measurement are diverse and the scope of the core measures is broad, the Committee concluded that the Secretary of HHS, as the nation’s senior and most visible health care policy maker and manager, is the logical leader to spearhead the multi-stakeholder effort of refinement, alignment, implementation, maintenance, and governance of the core measures at different levels of the health system. Leadership in the implementation of the core measure set also is required at other levels of the health system, including the community, county, and state levels, as well as from leadership within health stakeholder groups. For example, strong leadership on health at the corporate CEO level could orient care purchasing and planning decisions within a large company around the core measures so that meaningful comparisons could be made among care options, and health initiatives and policies could be focused on particular priorities or challenges in the health outcomes of the employee population. Similarly, leadership within the care system could enable collaboration and coordination with key community stakeholders by focusing on the outcomes of a patient population rather than the quality of care in isolation.

Strategy

In addition to a range of specific implementation priorities and considerations for different stakeholder groups, certain factors are critical for successful implementation that are common across stakeholders in the health system. Among these is the need for a strategic approach to implementing the core measures based on the local factors and considerations that matter most to a community or stakeholder group. While the core measures themselves present a standard approach to measuring priority outcomes, achieving the required level of data reporting and use will present different challenges for different groups. A thoughtful planning process with broad input from relevant parties could aid in supporting successful implementation by ensuring that responsibilities, challenges, and gaps are addressed early and that potential barriers to successful implementation are identified. The core measures could serve as a tool for strategy at multiple levels, including the state, local, and institutional levels. For example, a state governor could use the core measures as a dashboard for health—continually monitoring performance and progress in health and using the data produced to establish targeted improvement programs and strategies or to inform decisions about the allocation of funding. Similarly, a business leader could use the core measures as a tool for tailoring health spending, programming, and policy decisions to the particular needs, challenges, and priorities of the institution’s population.

Incentives Alignment

Core measures present an opportunity for aligning incentives across the health system by drawing attention to the outcomes that matter most for the nation’s progress toward health improvement. Many of the forces and incentives at play in the health system today are directed toward proxies or processes related to health rather than toward the true outcomes they are intended to influence. For example, fee-for-service models of care delivery incentivize the health care system to provide a high volume of services, although higher service volume does not necessarily equate to better outcomes or better quality of care. The core measures could be used to align incentives by a variety of organizations and at multiple levels. An accountable care organization charged with demonstrating impact on population health needs core measures as a straightforward and reliable assessment tool. Given the alignment of the core measures around health outcomes—which depend on a broad range of stakeholders both within and outside of the care system—the core measure set could serve as an incentive for enhanced coordination with outside groups, as well as promote innovative approaches to improving health that go beyond the provision of care services.

By focusing on a parsimonious set of high-level health elements, the core measure set could enable alignment of incentives across a broad range of stakeholder groups, potentially increasing the efficiency and effectiveness of the nation’s efforts to improve health and care quality, to control costs, and to engage individuals and communities in the process.

Infrastructure

Core measures require robust, interoperable infrastructure for the routine collection and reporting of key data elements. While progress is being made across the country in the development and use of digital infrastructure components such as electronic health records, the nationwide health data infrastructure is characterized by numerous different systems with limited interoperability, disparate levels of use, and approaches to use based on local factors and needs. While in the short term, core measures at different levels may be assembled from unconnected data systems and with varying levels of detail and coverage, in the long term, core measures could drive progress in infrastructure development and interoperability around those measures that are of the highest priority for understanding and measuring progress in the health system.

Culture

Achieving successful implementation of the core measures will depend on how well the measures—and the approaches to their implementation—align with the culture and priorities of a stakeholder group or community. In particular, the core measures may meet with resistance if presented as a tool for assigning accountability or for assessing pay based on performance. Further, the emphasis on data sharing and comparability embodied in the core measures may run counter to some cultural norms of competition or proprietary information. Successful implementation of the core measures will depend on the ability of local leaders to account for cultural factors that may present implementation challenges and to ensure that the approach to implementation is tailored to cultural norms and priorities.

Continuous Learning

Finally, the core measures are not intended to be static, but rather a set of priority measures that will evolve over time in accordance with the needs and capabilities of the health system. Therefore, a continuous learning approach to implementation of the core measures, emphasizing the dynamic nature of the measures and the implementation process, can ensure that the core measures will serve as a sustained and reliable guide to and prompt for improvement and progress through decades to come.