Existing Reporting Requirements
BIRTHS, DEATHS, AND REPORTING ON DISEASES OF CONCERN
In the United States, all vital events—such as births, deaths, and marriages—are recorded by local jurisdictions. These jurisdictions, including all 50 states, 5 territories, the District of Columbia, and New York City, vary in how they collect these data. Some have centralized vital records offices, while others have local registrars who manage the data. Jurisdictions also have local autonomy in the recording, processing, quality assurance, and analysis of the data. Although collected locally, the data are compiled nationally through a cooperative agreement with the National Center for Health Statistics in the Centers for Disease Control and Prevention (CDC). To ensure nationally uniform data, the agreement includes requirements for the data’s consistency, quality, and timeliness (NRC, 2009).
The value of these data is that they are not samples but represent almost all of the vital events that occur throughout the country. In fact, recent studies estimate that more than 99 percent of births and deaths are currently included (Guyer et al., 2000). From these data, the National Vital Statistics System can provide snapshots of the nation’s current status on a variety of dimensions, including (Guyer et al., 2000)
- death rates and life expectancy,
- leading causes of death,
- maternal and infant mortality rates, and
- population shifts.
These data can be analyzed to search for trends, make comparisons across states and countries, and assess progress (Kochanek et al., 2012).
In a similar fashion, the process of reporting certain diseases centers on local initiative. Each state has laws requiring that providers of health care—laboratories, hospitals, individual clinicians—report incidences of particular diseases to their state or local health department. As with vital statistics, these data come from 57 jurisdictions, which vary as to the specific notifiable diseases that must be reported (CDC, 2012b). The completeness of reporting varies as well, although it appears to depend more on the particular disease than on geographic location (CDC, 2012b; Doyle et al., 2002). One challenge is that there often is little connection between the data stored in electronic health records and public health disease surveillance systems, except in a limited number of pilot initiatives (Klompas et al., 2012a,b).
National figures are calculated voluntarily by states, which share portions of their data with the National Notifiable Diseases Surveillance System, operated by the CDC in collaboration with the Council of State and Territorial Epidemiologists. For example, the list of nationally notifiable infectious diseases is developed through a collaborative process in which the Council of State and Territorial Epidemiologists, with input from the CDC, makes annual recommendations for additions to and deletions from the list. As shown in Box B-1, almost 70 diseases were listed for 2013, ranging from anthrax to cholera to HIV to yellow fever (CDC, 2013).
At the state and local levels, these data assist with conducting disease surveillance, controlling outbreaks, and managing and evaluating prevention activities. At the national level, these data can help with monitoring disease trends, managing and evaluating prevention activities and strategies, identifying high-risk populations or regions, and identifying and controlling potential outbreaks (CDC, 2012a,b).
PAYER-REQUIRED REPORTING OF THE DELIVERY AND PERFORMANCE OF MEDICAL CARE
The Centers for Medicare & Medicaid Services (CMS) uses measures for multiple purposes—ranging from performance-based payment to public reporting—for the Medicare and Medicaid programs and the Children’s Health Insurance Program (CHIP). As Table B-1 illustrates, several hundred measures are currently in use in each of the measure categories. Table B-2 shows the focus of these measures, which tend to capture care processes. However, a significant number of measures are now devoted to assessing health outcomes. The measures address primarily ambulatory, inpatient, and home care, although measures exist for many other care settings (see Table B-3). Finally, Table B-4 shows that reported measures address care
BOX B-1
National Notifiable Infectious Conditions (2013)
Anthrax
Arboviral diseases, neuroinvasive and nonneuroinvasive
Babesiosis
Botulism
Brucellosis
Chancroid
Chlamydia trachomatis infection
Cholera
Coccidioidomycosis
Cryptosporidiosis
Cyclosporiasis
Dengue virus infections
Diphtheria
Ehrlichiosis and anaplasmosis
Giardiasis
Gonorrhea
Haemophilus influenzae, invasive disease
Hansen’s disease
Hantavirus pulmonary syndrome
Hemolytic uremic syndrome, postdiarrheal
Hepatitis A, acute
Hepatitis B, acute
Hepatitis B, chronic
Hepatitis B, perinatal infection
Hepatitis C, acute
Hepatitis C, past or present
HIV infection (AIDS has been reclassified as HIV Stage III)
Influenza-associated pediatric mortality
Invasive pneumococcal disease
Legionellosis
Listeriosis
Lyme disease
Malaria
Measles
Meningococcal disease
Mumps
Novel influenza A virus infections
Pertussis
Plague
Poliomyelitis, paralytic
Poliovirus infection, nonparalytic
Psittacosis
Q fever
Rabies, animal
Rabies, human
Rubella
Rubella, congenital syndrome
Salmonellosis
Severe acute respiratory syndrome–associated coronavirus disease
Shiga toxin-producing Escherichia coli
Shigellosis
Smallpox
Spotted fever rickettsiosis
Streptococcal toxic-shock syndrome
Syphilis
Tetanus
Toxic shock syndrome (other than streptococcal)
Trichinellosis
Tuberculosis
Tularemia
Typhoid fever
Vancomycin-intermediate staphylococcus aureus and vancomycin-resistant staphylococcus aureus
Varicella
Varicella deaths
Vibriosis
Viral hemorrhagic fever
Yellow fever
TABLE B-1 Uses for Measures Employed by the Centers for Medicare & Medicaid Services
Measure Use | Number of Measures |
Public reporting | 283 |
Quality reporting | 655 |
Pay for performance | 286 |
Pay for reporting | 84 |
NOTE: A measure may have multiple uses and may be represented in more than one category. As a result, sums of the table categories would be inaccurate.
SOURCE: U.S. Department of Health and Human Services Measure Inventory, 2013.
TABLE B-2 Focus of Measures Employed by the Centers for Medicare & Medicaid Services for Reporting Purposes
Measure Focus | Number of Measures |
Access | 21 |
Efficiency | 12 |
Outcome | 222 |
Patient experience | 41 |
Process | 580 |
Structure | 25 |
Other | 12 |
SOURCE: U.S. Department of Health and Human Services Measure Inventory, 2013.
quality and outcomes for a diverse group of conditions and topics, with the category of cardiovascular and stroke receiving particular attention.
PROGRAMS OPERATED UNDER WAIVER AUTHORITY
In Medicaid and CHIP, new delivery system models and payment strategies can be tested using waivers, which give states the flexibility to tailor programs to their needs and priorities. Currently, there are almost 400 active waivers (CMS, 2013).
Four primary types of waivers exist (CMS, 2013):
- research and demonstration waivers (section 1115),
- managed care waivers (section 1915(b)),
TABLE B-3 Care Settings for Reported Measures Employed by the Centers for Medicare & Medicaid Services
Care Setting | Number of Measures |
Ambulatory surgery center | 8 |
Ambulatory/office-based care | 469 |
Dialysis facility | 30 |
Home care | 101 |
Hospice | 2 |
Hospital inpatient | 194 |
Hospital outpatient | 28 |
Inpatient rehabilitation facility | 2 |
Long-term care facility | 39 |
Long-term care hospital | 5 |
Managed care plan | 33 |
Other | 2 |
SOURCE: U.S. Department of Health and Human Services Measure Inventory, 2013.
TABLE B-4 Selected Topics or Conditions for Reported Measures Employed by the Centers for Medicare & Medicaid Services
Condition/Topic | Number of Measures |
Cancer | 45 |
Cardiovascular and stroke | 137 |
Central nervous system (dementia, Parkinson’s, epilepsy) | 19 |
Chronic and elder care | 57 |
Communicable diseases (immunizations, methicillin-resistant staphylococcus aureus [MRSA], influenza) | 53 |
Dental | 4 |
Diabetes | 40 |
Mental health and substance abuse | 59 |
Musculoskeletal (osteoarthritis, rheumatoid arthritis, back pain) | 29 |
Patient experience | 47 |
Patient safety | 97 |
Respiratory conditions | 34 |
Surgical procedures | 54 |
SOURCE: U.S. Department of Health and Human Services Measure Inventory, 2013.
- home- and community-based services waivers (section 1915(c)), and
- continuum of care to the elderly and people with disabilities waivers (concurrent section 1915(b) and section 1915(c)).
In general, the research and demonstration waivers can allow for more comprehensive programmatic flexibility (although some are written quite narrowly), while the managed care and home- and community-based services waivers focus on specific populations and services. States can use research and demonstration waivers for testing new approaches, including expansion of coverage to individuals not otherwise eligible for Medicaid or CHIP, provision of coverage for services not typically covered by the program, or the application of delivery system innovations to improve the quality and value of care (Alker and Artiga, 2012; Artiga, 2011).
A research and demonstration waiver is approved through negotiations between the state and the U.S. Department of Health and Human Services (HHS) agencies, sometimes with the involvement of the U.S. Office of Management and Budget (OMB) as well. Once a waiver has been approved, the state receives an award letter explaining which specific sections of the Social Security Act or other regulations are being waived and describing the terms and conditions of approval. One important metric is the cost of the program, as all approved projects must be budget neutral to the federal government over the course of the waiver. Because these types of waivers are intended for research purposes, the state is required to have an approved evaluation strategy in place (Alker and Artiga, 2012; Artiga, 2011). Generally, states have substantial flexibility in how they carry out their evaluation—including experimental and other quantitative and qualitative designs—with the constraints that the final evaluation design must be approved by CMS and published publicly.1
The Patient Protection and Affordable Care Act (ACA) augmented waiver authority by creating the CMS Innovation Center, which has the ability to test, evaluate, and expand care delivery and payment models in Medicare, Medicaid, and CHIP. If these models are found to be successful, the Secretary of HHS has the authority to scale them up nationally. Again, there is flexibility in what constitutes success, and the CMS actuary must verify that these models lead to spending reductions. In addition, another section of the ACA provides for State Innovation Waivers, which will allow states to test new models for their insurance exchanges; qualified health plans; and other benefit, cost sharing, and coverage provisions (Alker and Artiga, 2012; Artiga, 2011).
_______________
1 42 CFR 431.424.
Public and private payers have introduced multiple new payment models to move away from fee-for-service payment and align incentives toward high-quality, high-value care. These new payment models often require clinicians and hospitals to collect and report multiple measures on care processes and outcomes. In some cases, financial incentives are tied directly to performance on a given measure, while in others the measure is used to ensure that quality and outcomes remain consistent under the new payment method (Schneider et al., 2011). Table B-5 shows the multiple categories of payment models currently in use and for each model, the categories of measures employed (in dark gray), as well as the categories of measures discussed in program documentation (in light gray). Table B-6 illustrates the care settings assessed by different payment models, demonstrating that some models are focused exclusively on one care setting, such as inpatient care, while others consider outcomes from all settings.
REPORTING ON FEDERAL CATEGORICAL GRANT PROGRAMS
Federal grants to state and local governments are significant, accounting for more than $600 billion in fiscal year 2011, and the number of such grant programs has increased over the past three decades. The focus of these grant programs has shifted over time, with an increase in funding for Medicaid and other health programs and a decrease in funding for other activities. In recent reviews of federal grants, the U.S. Government Accountability Office (GAO) found a lack of appropriate performance measures and accurate data for agencies to use in assessing the performance of grant programs and ensuring that grant funds are being spent effectively (GAO, 2006, 2012). The specific measures and strategies used to assess performance and provide for accountability vary, with the details being determined by authorizing and appropriations legislation; the agency’s grant management, such as funding announcements and notification processes; and government-wide grant management legislation, regulations, and executive orders. Given the multiple types of federal grants—from categorical grants that focus on one activity to block grants that allow choice among a range of activities—some programs may want to provide for substantial flexibility in their assessment, while others may want to provide for greater accountability (GAO, 2006). Furthermore, agencies often are challenged by a lack of accurate and credible performance data, especially when those data are provided through third parties (GAO, 2012).
States have a long history of publicly reporting information on health care performance. One of the first state performance reports came from the New York State Department of Health, which in 1989 started publishing data on risk-adjusted mortality for cardiac bypass surgery (Chassin, 2002). The number of such programs has continued to grow, and at least half of
TABLE B-5 Reporting Requirements for Different Payment Models by Measure Focus
Payment Reform Models | |||||||||||||
Measurement Domain | Global Payment | ACO Shared Saving Program | Medical Home | Bundled Payment | Hospital-Physician Gain-sharing | Payment for Coordination | Hospital P4P | Payment Adjustment for Readmissions | Payment Adjustment for Hospital-Acquired Conditions | Physician P4P | Payment for Shared Decision Making | ||
Outcome | Mortality | ||||||||||||
Health status | Morbidity | ||||||||||||
Functional status | |||||||||||||
Health-related QoL | |||||||||||||
Safety Outcomes | |||||||||||||
Patient experience/satisfaction | |||||||||||||
Other outcome | |||||||||||||
Process | Population health | Preventive services | |||||||||||
Healthy behaviors | |||||||||||||
Clinical care | |||||||||||||
Care coordination | |||||||||||||
Patient/family/caregiver engagement | |||||||||||||
Safety practices | |||||||||||||
Other process |
Cost/resource use | Per capita | ||||||||||||
Episode | |||||||||||||
Service | Imaging | ||||||||||||
Hospital LOS | |||||||||||||
Hospital readmits | |||||||||||||
ER/ED visits | |||||||||||||
Antibiotic prescribing | |||||||||||||
Other | |||||||||||||
Other cost/resource use | |||||||||||||
Structure | HIT utilization | ||||||||||||
Management | |||||||||||||
Other structure | |||||||||||||
Access | |||||||||||||
Composite | |||||||||||||
Other measurement domain |
NOTES: No shading: no measure statements, measures, or measure sets in program documentation.
Light shading: measure statements, but no measures or measure sets in program documentation.
Dark shading: specific measures or measure sets fit within this domain, or program documentation names a specific measurement algorithm.
ACO = accountable care organization; ER/ED = emergency room/emergency department; HIT = health information technology; LOS = length of
stay; P4P = pay for performance; QoL = quality of life.
SOURCE: Schneider et al., 2011.
TABLE B-6 Reporting Requirements for Payment Models Organized by Their Care Setting
Payment Reform Models | |||||||||||||
Measurement Domain | Global Payment | ACO Shared Saving Program | Medical Home | Bundled Payment | Hospital-Physician Gain-sharing | Payment for Coordination | Hospital P4P | Payment Adjustment for Readmissions | Payment Adjustment for Hospital-Acquired Conditions | Physician P4P | Payment for Shared Decision Making | ||
Clinician office | |||||||||||||
Hospital/acute care facility | Inpatient | ||||||||||||
Outpatient | ER/ED | ||||||||||||
Surgery/ASC | |||||||||||||
Laboratory | |||||||||||||
Imaging | |||||||||||||
Clinic | |||||||||||||
Other outpatient |
Post acute/ LTC | Nursing home/SNF | ||||||||||||
Rehabilitation | |||||||||||||
Other post acute/LTC | |||||||||||||
Home health | |||||||||||||
Hospice | |||||||||||||
Dialysis facility | |||||||||||||
Ambulance | |||||||||||||
Other setting |
NOTES: No shading: setting not mentioned in program documentation.
Light shading: setting mentioned in program documentation.
ACO = accountable care organization; ASC = ambulatory surgery center; ER/ED = emergency room/emergency department; HIT = health informa-
tion technology; LTC = long-term care; P4P = pay for performance; SNF = skilled nursing facility.
SOURCE: Schneider et al., 2011.
the states now sponsor a public reporting program focused on care quality. These programs vary considerably as to whether they include information on care processes or health outcomes, whether they describe performance only for common diseases or for many diseases, and how their data are generated (Ross et al., 2010). In addition to public reporting, more than half of all states operate a hospital adverse event reporting system, which requires that the hospital report the incidence of specific types of patient harm. These systems vary significantly from state to state with respect to what types of adverse events must be reported (Levinson, 2008; Wright, 2012).
REPORTING TO REGULATORY AND CERTIFICATION BODIES
A variety of organizations are involved with accreditation of health care in the United States, including the Joint Commission and the National Committee for Quality Assurance (NCQA). The Joint Commission accredits approximately 20,000 health care organizations and programs, while NCQA accredits health plans and offers voluntary programs for new care delivery models (Berenson et al., 2013).
COMMON THEMES AMONG REQUIREMENTS
In a recent review of measures, RAND Corporation found that many organizations are using measures for multiple purposes, which implies that they are realizing the value of aligning measures across uses. RAND also found that measures are used most commonly for quality improvement and public reporting, while payment uses are almost half as common, and an even smaller number of measures are used for accreditation, certification, credentialing, and licensure. Process measures are the most commonly used type of measure, and claims and administrative data are the most common data sources used to calculate measures (Damberg et al., 2011).
This section describes characteristics of publicly reported measures based on data from the National Quality Measures Clearinghouse. This clearinghouse, a project of the Agency for Healthcare Research and Quality (AHRQ), contains more than 2,000 different quality measures that are in use or have recently been tested. An analysis of the subset of clearinghouse measures that are used for public reporting shows that most focus on the effectiveness of clinical prevention and treatment, with fewer being devoted to other National Quality Strategy aims (see Table B-7). Further, Table B-8 illustrates that publicly reported measures focus on ambulatory care, inpatient settings, and managed care plans, although they address many other elements of the health system as well.
TABLE B-7 Number of Publicly Reported Measures by Aim of the National Quality Strategy
National Quality Strategy Aim | Number of Publicly Reported Measures |
Effective communication and care coordination | 16 |
Health and well-being of communities | 121 |
Making care safer | 42 |
Making quality care more affordable | 4 |
Person- and family-centered care | 83 |
Prevention and treatment of leading causes of mortality | 312 |
SOURCE: Analysis of National Quality Measures Clearinghouse data. Accessed May 31, 2013.
TABLE B-8 Number of Publicly Reported Measures by Setting or Organization Assessed
Element of the Health System | Number of Publicly Reported Measures |
Ambulatory/office-based care | 159 |
Ancillary services | 16 |
Assisted living facilities | 0 |
Behavioral health care | 10 |
Community health care | 20 |
Emergency medical services | 11 |
Emergency room | 9 |
Home care | 21 |
Hospices | 9 |
Hospital inpatient | 89 |
Hospital outpatient | 14 |
Intensive care units | 4 |
Managed care plans | 88 |
Rehabilitation centers | 11 |
Residential care facilities | 12 |
Rural health care | 10 |
Skilled nursing facilities | 15 |
Substance use treatment programs/centers | 1 |
Transition | 16 |
SOURCE: Analysis of National Quality Measures Clearinghouse data. Accessed May 31, 2013.
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