Core measures are basic to gauging the overall health of the nation; performance in health and health care at various levels; and how performance compares from organization to organization, community to community, state to state, and country to country. The availability of reliable standardized measures will make all of these assessments possible. But identifying the core measure set is merely the starting point; their uptake and use will be the real challenge.
Successful implementation of the core measure set will depend on its relevance, quality, and utility to stakeholders. The introduction of any new activity into a complex environment must account for the multiple competing priorities of stakeholders, the degree of change proposed, and the overall pace of change in the system. The U.S. health care landscape is already undergoing vast changes, including financial reform, improved access, the introduction of new technologies, better consumer access to health information, increased interest in primary care and prevention, and a stronger focus on accountability. Each of these changes carries the potential for new measure requirements and accompanying reporting burden, underscoring the importance of a new measurement framework—a framework that registers and reports overall system performance on the most vital dimensions in a comparable fashion at every level while reserving to local prerogative decisions on measures tailored to specific needs. Hence, the core measure set presented herein is prompted by the need for a paradigm change in the approach to assessment and reporting at all levels.
Although full system-wide implementation of the core measure set should pave the way for harmonization of disparate measures and reduction
of the measurement burden, core measures clearly are not intended to replace all other measurement efforts. Rather, core measures will provide a common platform upon which tailored but aligned measure sets can be constructed. The goal is to ensure the availability and utility of the most critical measures and information while affording greater local and institutional discretion on complementary measures that provide detailed information needed to empower performance improvement.
Measurement of a selected number of relevant targets should better direct efforts to improve the aspects of health that are most compelling to all. With appropriate organizational infrastructure to collect, store, share, and communicate data, the burden of measurement will likely be mitigated as less relevant measures are abandoned. Strategic introduction of the core measures should set the stage for their widespread adoption, utilization, and sharing across organizations and communities. In this way, core measures can serve as tools for measuring progress, recognizing shortfalls, informing and raising public awareness, sharpening focus at multiple levels, improving accountability, fostering diverse data linkages, facilitating informed patient choice, and establishing targets for community efforts. This chapter begins by reviewing in turn each of these practical applications of the core measure set. It then describes the uses of the core measures in assisting and assessing various large societal initiatives and in leveraging existing programs and requirements. Next is a discussion of implementation challenges for stakeholders at multiple levels. The final section addresses the crucial process of continuous improvement of the core measure set and each measure within it.
One of the primary purposes of measurement is to provide structured, objective information on performance. Such information enables comparisons of performance across different groups or relative to benchmarks. Similarly, performance on a set of measures enables assessment of the health system’s functioning at multiple levels and of progress toward better health at lower cost. Focus on a core set of measures promotes learning and complementary action. When success in reducing overweight and obesity is achieved in a particular population or community, that progress, and the reasons for it, can offer insight and prompt action for others. Consistent, reinforcing measurement may not be essential for progress to occur—some progress is, after all, the product of new scientific knowledge or of other social or environmental changes—but the act of measuring what is most
important is almost certain to enhance the efficiency and effectiveness of improvement efforts.
Perhaps the most important result of measurement is to drive the recognition of shortfalls and to register failures, either for the population as a whole or for component groups. Only by recognizing that results are falling short relative to an expectation of what is possible given knowledge and resources, or relative to some comparison group, can the necessary attention, assessment, and action be mobilized to address the discrepancies. Currently, because information is gathered and reported unevenly and inconsistently in different places and at different levels, delays occur in recognizing even the most basic and important problems. If life expectancy for certain populations in the United States is actually declining, as has been reported for African American women in some counties, a special study should not be required to identify the development and to trigger assessment. It is a vital indication of a systemic problem that should be a constant and consistent focus of attention at every level.
Although the primary purpose of a core measure set is monitoring status and trends to accelerate progress or reverse setbacks, marshaling public support and demand for the necessary action requires a public sense of priority. Inherent in the parsimonious character of the core measure set proposed herein is the ability to educate the public—indeed, all stakeholders—about what is really most important to the nation’s health and well-being. Despite the fact that more and more health information is being publicly reported, uptake and assimilation of that information by the public is limited. The unsystematic presentation of existing quality, safety, and cost data, for example, has constrained the meaningfulness of the data to the general public (James, 2012). While clinicians may be affected by public reporting of the performance of providers or provider organizations, this information does not yet appear to be a major driver of consumer behavior in choosing a provider, with the possible exception of maternity care and certain elective procedures. For the public, a more accessible approach, based on simple marketing principles, is needed to build familiarity, comfort levels, and utility. The starting point is parsimony and consistency, which also will facilitate the use of presentation strategies that improve accessibility to and retention by the public.
Just as the volume and inconsistency of reporting on health issues have impeded the public’s grasp of the issues most meaningful to their health status and health prospects, the proliferation of measures has blunted the focus of stakeholders on the levers most important to the outcomes they seek. Measures most used for assessing progress may be those that are the most popular, the most controversial, or the easiest to implement, or those that simply have been in use the longest. They may not accurately reflect a community’s or system’s status or progress with respect to health, quality of care, or value. Measuring and reporting whether patients like their doctor, for example, offers little insight on the extent to which they are receiving treatment based on the best evidence or their care is aligned with the goals most important to them. By focusing consistently over time on a small number of high-priority measures, a core measure set affords the opportunity for decision makers at multiple levels—national, state, local, and institutional—to sharpen their focus and their cooperation on and coordination of priorities.
As focus sharpens through consistent attention to core measures, the opportunity for meaningful accountability will improve. Across the broad and diverse range of activities that make up the elements of health care in the United States, progress is measured in myriad ways with varying levels of validity and generalizability, and hence with varying certainty on the loci of responsibility. Most system incentives are organized around the delivery of and payment for various units of service rather than outcomes or performance at various levels. Using the common language of a core measure set to assess progress presents an opportunity to promote shared accountability across the health system for the goals that matter most for improving health at the national, state, and local levels. Similarly conveyed is the reality that health leadership at each of these levels also is accountable for reaching outside clinic doors to forge partnerships at the community level. Access to needed care for patients with diabetes, for example, is a function of more than simply wait times or insurance coverage; at its most basic level it also means mobilizing the community capacity to identify and engage those at high risk and to ensure follow-up through community-level resources. As population and health care system measures, the core measure set offers the prospect for a more meaningful and longer-term view of accountability.
Effective, efficient, well-coordinated system-wide efforts to improve health depend on seamless access to information and data from multiple sources and levels of the health care system. Data must be shared within and across institutions and actors and among the various loci of activity to enable meaningful measurement and use for improvement. The core measures proposed herein require various data sources, including clinical data, claims data, biometric data, and patient-reported data. Each will need to be collected and shared in a standard way to enable standard reporting, comparability, and benchmarking.
Quality and outcome measures are best derived from clinical data, while cost and utilization measures usually are constructed from administrative data. To have a complete picture of value, each type of data must be aggregated and shared with appropriate privacy safeguards, but with the purpose of enabling transparency with respect to performance. Quality measures based on data derived from multiple independent units of interest—such as practices, health plans, hospitals, counties, or health systems—tend to be more valid and reliable than those calculated from a single unit. Within any community, moreover, including data from multiple sources offers a more representative and comprehensive view of health and health care. Purchasers also need a robust multi-payer source of information on health care quality and value in aggregate form to understand total cost of care and to establish benchmarks. For true population health management and reductions in total cost of care, data contributions from a broad spectrum of care and community-based providers, public health and social service agencies, long-term care providers, and others will be necessary to enable measurement of the quality and efficiency of care delivery and health outcomes across settings of care and time.
National data aggregation is useful to heighten attention to quality, identify general areas of variation, develop benchmarks, and inform and stimulate policy. Regional aggregated data are needed to design responses to local priorities, gain the trust of providers and help them take ownership of problems, and target improvement efforts. Programs at the federal or state level aimed at safeguarding the health of children with respect to vaccine-preventable diseases need information on the immunization levels of children and the particular vulnerabilities present at the community, neighborhood, or even institutional level. The importance of this information goes beyond the specific issue of infectious disease prevention because it also tends to reflect the overall integrity of care delivery protocols and safeguards on a variety of important dimensions. Certain reporting requirements and patterns—births, deaths, and reportable diseases—currently are implemented in a relatively common and well-coordinated fashion, but
most of the measures making up the core set presented herein are available only sporadically at various levels and, even then, with spotty consistency and comparability. The core measure set can inform data collection and design of the data set. As an example, to report price and cost requires receipt of all cost elements in claims data. This is necessary not only for the reliability and integrity of the data collected at multiple levels but also for dependable guidance for program implementation and refinement.
Growing awareness that effective care depends on the engagement of patients and families underscores the need for better information on provider performance and on the appropriateness of various clinical services. To date, however, this information has been sparse at best and, more commonly, virtually inaccessible. To address this need for information on clinicians, the Centers for Medicare & Medicaid Services (CMS) is expanding its Physician Compare website to include quality measure data on group practices and accountable care organizations (ACOs) to help patients make informed choices about their health care (CMS, 2014). With respect to informed patient choices about treatment, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign to enable conversations between doctors and patients about unnecessary care and, by extension, to identify and reduce the use of services that are commonly delivered for which evidence is lacking. Effective implementation and expansion of such initiatives requires clinician confidence in and public understanding of the reliability, interpretability, and limitations of comparison data—a comfort level. This confidence and understanding can be enhanced through sustained exposure to and familiarity with an ongoing resource of the sort provided by the core measure set. Over time, the core set is intended to carry an element of familiarity and shared ownership of the measurement process to benefit decisions at all levels.
At the broadest level, the core measure set offers the opportunity for national, state, and local leaders to translate into clear and consistent terms the issues that are most important to progress in health at the levels of their focus and responsibilities. By targeting the highest-priority issues for the entire health system, the core measures therefore can serve as a vehicle for promoting community-wide collaboration and investment and the implementation of initiatives aimed at improving performance on the targeted issues. Especially important in this respect is the extent to which the core measure set makes clear the dependence of progress in health on overall
community-wide involvement, and hence on the involvement and mobilization of multiple sectors. Governors, mayors, and other such leaders can use their bully pulpit to recruit, organize, and steward the work of various individuals and organizations on behalf of progress in the target areas of the core measures, and they can use the measures to demonstrate areas of particular priority as well as to demonstrate progress. The core measure set can help streamline, harmonize, and accelerate the mobilization of efforts focused on the important targets. By virtue of the linkages and cooperative planning already enabled by work around issues in the core measure set, a local health officer will have established the ongoing relationships necessary for cooperative community action—for example, against the appearance of a newly emerging infectious disease such as severe acute respiratory syndrome (SARS) or Ebola. Building familiarity and cooperation through work around the core measure set will improve overall system readiness. Critical to realizing opportunities at the community level is coordination and collaboration among a broad group of stakeholders in a community, including public- and private-sector groups, employers, community health organizations, public health agencies, and more.
In addition to the practical applications described above, the core measure set is of central utility in drawing attention to, illustrating, and tracking progress on large, cross-cutting initiatives of social importance. Examples currently under way include those devoted to achieving greater health equity, accelerating progress toward what the Institute for Healthcare Improvement (IHI) has termed the Triple Aim®, implementing the National Prevention Strategy and the National Quality Strategy, and achieving the affordable care agenda inherent in the Patient Protection and Affordable Care Act (ACA).
Disparities in health prospects and outcomes represent a significant national challenge, in particular when those disparities are related to economical, social, or environmental disadvantage and represent matters of health equity (HHS, 2011). Individuals from minority racial and ethnic backgrounds experience a higher incidence and severity of certain diseases and health conditions relative to white individuals (APHA, 2013). For instance, one study found that the rate of hospitalization for uncontrolled diabetes without complications was almost 5 times higher in African Americans and 3.6 times higher in Hispanics than in non-Hispanic Caucasian
patients (Russo et al., 2006). Moreover, in 2011, African Americans made up 12 percent of the U.S. population but accounted for 42 percent of all Americans living with HIV/AIDS (Perkins et al., 2013). A similar disparity is seen in self-reported outcomes. While 70.5 percent of non-Hispanic white persons reported excellent or very good health in 2013, this was the case for 60.1 percent of non-Hispanic African American persons and 57.7 percent of Hispanic persons (CDC, 2013). Socioeconomic challenges also present barriers to accessing health resources and services (CDC, 2010). According to the Medical Expenditure Panel Survey, 7 percent of high-income individuals experienced difficulty in receiving care as compared with 15 percent of people living below the federal poverty level (AHRQ, 2012). Children living in families with incomes below the federal poverty level also had lower vaccine coverage than did children living in families at or above the poverty level (CDC, 2012). Disparities in the quality of care may be seen as well, as suggested by the observation that racial minorities experience more avoidable procedures, avoidable hospitalizations, and untreated disease relative to white individuals (Fiscella et al., 2000). Because of the persistence of disparities throughout the nation, the U.S. Department of Health and Human Services (HHS) has charged the Agency for Healthcare Research and Quality with the annual development of a National Healthcare Disparities Report. With consistent application of the core measure set at multiple levels, this report could provide a much more robust sense of the opportunities of particular importance and promise.
The core measure set proposed by the Committee can be used to help track and promote progress toward the Triple Aim. This term originated with IHI in 2007 and is widely used to characterize the critical goals of health and health care: improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care. The Triple Aim terminology maps well to the domains of influence—healthy people, quality of care, costs of care, and people’s engagement in health and health care—utilized by the Committee in identifying areas for action and corresponding core measures designed to achieve better health at lower cost (see Figure 5-1).
Similarly, and in a variation on the theme, the U.S. Department of Defense (DOD) has adapted the IHI’s Triple Aim concept to its own priorities. Because such important elements of the responsibilities of the Military Health System (MHS) revolve around preparedness and the ability to mobilize a rapid response to unexpected circumstances, the MHS in 2011 developed the Quadruple Aim for military personnel, which adds to the Triple Aim a fourth dimension—readiness, defined as “enabling a medically ready
FIGURE 5-1 Key health domains.
force, a ready medical force, and resiliency of all MHS personnel” (MHS, 2010). For either the Triple Aim or the four-part aim, a core measure set that affords regular and reliable access to information at multiple levels on the factors most important to improving health outcomes is a necessary tool for effective action. The fundamental difference of these approaches to articulating aims is that the health care system’s purpose is to enable citizens to fully engage in the activities of their daily lives, not readiness to engage with the health care delivery system. This requires different prioritization of resources to enable health—not treat disease—and different roles and relationships among health care and community-based organizations.
The landmark Institute of Medicine (IOM) report Crossing the Quality Chasm, defined the six aims for quality as care that is safe, effective, patient-centered, timely, efficient, and equitable. The IOM definition of quality is reflective of the Committee’s intent and was an important starting point in the Committee’s deliberations about quality of care measures. However, the six-item care definition was not specifically mapped onto the core set, as the Committee wanted to achieve a more parsimonious approach than the IOM definition allowed. Safe, effective, patient-centered, and timely are each explicitly included in the quality care core measures (patient safety, evidence-based care, care match with patient goals, and care access). Equity was not included within the quality domain, as the
Committee concluded that its importance required its embedding throughout—including in healthy people, cost, and engagement as well. In the realm of efficiency, the Committee concluded that the highest priority issue was the cost of care, which was indicated as a separate domain in the statement of task. In this way, the spirit of the six aims for quality was foundational to the Committee’s articulation of the core measure set, and the Committee’s definition of quality was the same, though the final framework of the set around the four aims described in the statement of task required an alternative approach to presentation.
In 2011, HHS released the National Prevention Strategy, establishing the goal of increasing the number of Americans who are healthy at every stage of life and underscoring the vision of a nation focused on prevention and wellness. The National Prevention Strategy outlines strategic directions oriented toward healthy and safe community environments, clinical and community preventive services, empowered people, and elimination of health disparities. In so doing, it in effect lays out an approach to achieving the national goals and objectives of Healthy People 2020, which identify what the nation ought to achieve by 2020 if attention and action can be mobilized. Accomplishment of these goals and objectives successful implementation of the anticipated strategies will address some of the most difficult health challenges faced by the nation, with seven specified priorities: tobacco-free living, preventing drug abuse and excessive alcohol use, healthy eating, active living, injury- and violence-free living, reproductive and sexual health, and mental and emotional well-being. Although the core measures identified by the Committee reflect parsimony, progress against these priorities will depend on the multilevel information that can be generated through implementation of the core measures.
Also in 2011, HHS released the National Quality Strategy, established with the aim of providing better-quality, more affordable care for individuals and communities. Development of the National Quality Strategy, which was mandated by the ACA, was led by the Agency for Healthcare Research and Quality. It focuses on six priority areas: making care safer, ensuring the engagement of all individuals and families in their care, improving care communication and coordination, promoting effective prevention and treatment for the leading causes of death, advancing best community practices for healthy living, and making quality care more affordable. Also identified are nine levers that can be used by stakeholders to implement the strategy.
A central element of the strategy is aimed at aligning clinical measures. Accordingly, the HHS Measurement Policy Council was convened to begin aligning measures across HHS—for example, for hypertension control, hospital-acquired conditions, patient safety, smoking cessation, patient satisfaction, obesity, depression screening, and care coordination. With its focus on systematic, systemic, and continuously improving assessment of such issues as evidence-based care, care match with patient goals, spending burden, and individual and community engagement, the core measure set proposed by the Committee will provide critical multilevel insight and guidance for progress on the National Quality Strategy.
Despite the long-standing and mounting concern about the personal and national impact of health care costs, the rate of increase in those costs continues to outpace cost and price increases throughout the rest of the economy. Further, evidence suggests that costs of care vary widely among geographic areas and institutions, without corresponding variation in quality of care. The ACA contains provisions aimed at improving transparency in health care costs and providing incentives for their containment, including provisions related to ACOs. Progress is unlikely to achieve its potential until better information is available in a comparable fashion from the places where payments are designed and care is delivered. Additional insight is needed into pricing and resource utilization and their relative contribution to the total cost of care. Implementation of the core measures system-wide will provide insight on the personal burden of health care expenditures and, in a unique fashion, will facilitate more granular perspectives on how places vary in their resource use according to population and population purchasing power, reflecting the implications of these factors more precisely.
Because core measures are not intended to replace the full landscape of health measurement, the extent to which they complement and enhance various existing activities is an important consideration for their design and application. This section describes how the core measures can be used to enhance the effectiveness and efficiency of several priority programs with measure reporting requirements, addressing, in turn, electronic health records (Meaningful Use), accountable care, health care payers and purchasers, state Medicaid waivers, categorical health grants, community health planning, and community benefit programs (see Table 5-1).
TABLE 5-1 Applications of the Core Measure Set for Existing Programs/Requirements
|Activity||Utility of Core Measures|
|Meaningful Use Program||Provide standardized elements for every electronic health record, contributing reliability and comparability to information on health and health system performance and advancing the goal of Meaningful Use.|
|Accountable care||Facilitate comparability in the application of the 33 accountable care organization (ACO) measures, and provide an important tool for gauging the extent to which an ACO is delivering on the intended care, cost, and population health outcomes.|
|Payers and purchasers||Provide a stronger, more sustained focus on outcomes and costs with standardized tools for assessing the performance of health care organizations and clinician performance and results for covered populations.|
|State Medicaid waivers||Streamline and standardize the assessment and comparison of performance in improving core health outcomes under different circumstances and forms of waiver authority and across states, counties, facilities, and time.|
|Categorical health grants||Enhance comparisons across sites and time; help identify best practices across programs, communities, and states; and facilitate look-back studies aimed at identifying post-grant results on certain important outcome dimensions.|
|Community health planning||Provide well-timed assessment of progress and changing needs for attention and resources, especially important to meeting growing responsibilities of health systems for population health improvement.|
|Community benefit requirements||Focus community benefit initiatives on issues most important to outcomes, and improve prospects for targeted coordination of efforts involving multiple organizations.|
|Related health care reform provisions||Increase the quality and transparency to consumers of health, health care, and cost information to assist in their health and health care choices.|
The federal government’s Meaningful Use Program, administered by CMS in coordination with the Office of the National Coordinator for Health Information Technology, provides incentives for providers—hospitals and health professionals—to maximize the potential benefits of electronic health records. In this program, benchmarks have been set for providers to use in showing progressive capability in the use of electronic health records through three program stages. The embedded objectives relate to a range of clinical priorities—health outcomes, clinical processes, patient safety, care coordination, patient engagement, population and public health, and use of clinical guidelines—as well as to data and definition standardization and sharing capacity. Incorporation of the core measure set as a basic Meaningful Use feature would provide standardized elements for all electronic health records, contributing reliability and comparability to information on health and health system performance, increasing the prospects for seamless interoperability in the records’ sharing and use, and accelerating advancement toward the program’s basic clinical priorities. Full application will require a practical means of introducing population health elements.
Increasing awareness of the occurrence of medical errors, along with concerns about unwarranted and unsustainable costs, has prompted a stronger focus on accountability in health care. To provide incentives for care models that can achieve improved outcomes while controlling costs, the ACA contains several provisions designed to stimulate the development of ACOs and increase emphasis on care coordination and management and on prevention (McClellan et al., 2014).
The several hundred ACOs now in operation are diverse organizations. Because, through programs such as the Medicare Shared Savings Program and the Pioneer ACO Model Program, CMS has been a major driver in the development of ACOs, the agency has developed 33 measures for use in assessing their performance. Those measures are intended to facilitate the internal planning and operations of ACOs, as well as to assist CMS and other stakeholders in evaluating the quality and success of different facilities, different programs, and different approaches. Those 33 measures include several that target patient and caregiver experience, care coordination and patient safety, preventive health, and management of patients at high risk for certain diseases. The core measure set proposed by the Committee will facilitate comparability in the application of the ACO measures and
provide a needed tool for gauging the extent to which an ACO is delivering on the care and population health outcomes intended.
Approximately four dozen sizable health insurance companies, plus Medicare, currently operate in the United States, each traditionally collecting data in various ways that are substantially uncoordinated, unavailable for the generation of new knowledge, and certainly unstandardized. With progress toward expanded access to health insurance via health exchanges formed by states and the federal government, and with increasing demands for transparency of information on cost and quality in the health care system, the potential is developing to draw on substantially expanded databases for new insights into the effectiveness and efficiency of care. Still, the many technical, market, and regulatory barriers to progress will hinder the ability to put the data to the best uses possible. Application of the core measure set across all payers as commonly collected data points can serve as a valuable tool for assessing basic important outcomes across providers, plans, and circumstances. Further, use of the core measure set can enable employers and health plans to better assess and understand the characteristics and needs of their populations and, by extension, to develop priorities and tailored interventions for achieving better health at lower cost. Progress toward this enhanced availability and use of data is illustrated by state and regional all-payer claims databases, which are used in states and regions to aggregate claims data for measurement and reporting. This includes the 13 Qualified Entities designated by CMS to receive identified Medicare data for the purpose of public reporting on provider performance. This federal designation creates a framework for transparency through the use of Medicare data by regional entities that have demonstrated an ability to aggregate and use commercial claims data for measurement and reporting, a framework that can be expanded.
Medicaid covers nearly 70 million people in the United States and finances about 16 percent of all health care expenditures. With about one of five state dollars going to Medicaid expenditures—ranking behind only education as the largest state expenditure—Medicaid growth is of major interest and concern to states across the country. Especially with Medicaid programs expanding under the ACA and serving some of the highest-risk, most medically complex populations, states are seeking waivers from HHS to allow them greater flexibility in tailoring program expenditures to their needs and opportunities. There are currently four types of waivers
available to states for testing tailored, sometimes novel approaches to the payment and delivery of services in Medicaid and the Children’s Health Insurance Program: Section 1115 research and demonstration projects for approaches to structuring payments; Section 1915(b) projects for providing services through managed care systems; Section 1915(c) waivers for providing home- and community-based (rather than institutional) services, and concurrent (b) and (c) waivers emphasizing service continuity for the elderly or disabled. Because the waiver programs are aimed at identifying ways of improving outcomes while lowering costs, and because there is great heterogeneity across programs, assessing their results in a reliable and comparable fashion across states is very difficult, particularly when so many of the measures employed focus on process performance. Orienting accountability reporting around a standardized set of core measures can facilitate assessment of performance on core outcomes and provide for the meaningful ability to compare results across states, counties, facilities, and time under different circumstances and forms of waivers.
With programs targeting various health priorities—from preventive services such as immunization, high blood pressure control, and cancer screening to treatment services for those with HIV/AIDS, alcohol and drug abuse, and kidney disease—in the range of 200 categorical health grant programs are administered by various agencies within HHS. Each of these grants has data collection and reporting requirements, and apart from data that are highly specific to the targeted condition, many of these requirements are aimed at gathering similar information but from different perspectives, and not in a standardized fashion. The heterogeneity of measures in use by these types of programs limits comparability and meaningful assessment, as it may be difficult to conclude that a project is successful without the ability to compare both across time and among different facilities, regions, or programs. The measures selected often target care processes rather than outcomes that may result directly or indirectly from the services made available through the grant. In addition, outcomes specific to the grant’s targeted condition may not materialize until sometime after the grant has ended, rendering knowledge about life expectancy, well-being, or other possible outcomes of clear importance to the patient inaccessible. Ensuring that all categorical grant programs are generating standardized data points around the core measure set not only can facilitate assessment of various outcomes across time and sites but also may allow look-back assessments for results occurring after a grant’s conclusion.
Community health planning depends on the capacity to assess health status and needs routinely and reliably across demographic and geographic clusters. Moreover, coordination and comparable assessment strategies are needed among the various public and private stakeholders involved in the activity. These needs take on new urgency with increasing recognition of the need for community-based strategies for population health improvement as a core responsibility of the health care system. By focusing collective attention on the highest-priority issues for the health system as a whole, core measures have the potential to promote collaboration and adoption of a shared agenda, as well as to serve as a tool that enables participants to see progress and identify challenges earlier in the course. Economic incentives are now in play as well. The ACA requires health care institutions that are tax-exempt—about 60 percent of U.S. hospitals are nonprofit—to invest in community health assessments and community benefit activities that address critical community needs. This parallels the 5-year time frame for public health departments’ Community Health Needs Assessment, creating a potential opportunity for harmonization. The core measure set provides an essential tool for all institutions in a community seeking a reliable and sustained source of insight on gaps and progress, and depending on how the U.S. Department of the Treasury provides guidance and structures its approval processes, the set could serve as a means of fostering community collaboration among multiple institutions.
The development, adoption, implementation, maintenance, and continuous improvement of the core measure set will face many challenges at every stage—challenges that require explicit acknowledgment and aggressive cooperative engagement on the part of the entire stakeholder community if the full potential of the core measures is to be achieved. These challenges include limitations of the existing measurement infrastructure, variability in the approaches to measurement taken by different actors, the need for financial and personnel investments, legal and regulatory barriers, the need to assess relevance to multiple circumstances and stakeholders, and issues of trust and attribution.
Since a combination of data from patient claims, clinical experience, patient reports, regular surveys, and public health sources is required to
produce the core measures in a standardized, consistent, reliable, and sustained fashion, it is necessary to have a measurement infrastructure that is multifaceted, with seamless interfaces among components. The small size of the core measure set enhances its feasibility, but its implementation will require deliberate strategy and strong leadership. Implementing the core measures will require infrastructure that can consistently capture the key data elements needed to populate the measures and can exchange those data elements across populations and data systems. Although progress is being made toward this goal, there remains a significant gap between the current reality of data availability and collection and what is needed to support a nationwide core measures set.
At present, data are rarely available across provider organizations, payers, or patient populations because of restrictions on data sharing and proprietary interests. The current fragmentation will not meet the needs of individuals or organizations, nor will it support the capacity for regular assessment across the full landscape of organizations and individuals involved in the health system. Despite an investment of significant resources, there remains a patchwork of independent claims data and electronic health record systems that fail to capture key data elements in consistent formats and cannot readily exchange those elements across systems. To develop a core measurement environment that encompasses the full breadth of the health system and provides high-quality, useful data, significant advances and improvements in digital infrastructure and analytic capacity will be necessary. The need for infrastructure development is particularly acute in health venues such as long-term care facilities and rehabilitation centers, which fall outside of traditional hospitals and health systems. Encouraging the development of infrastructure capacity in these venues will be a key challenge for the development of measures that meaningfully reflect the health system as a whole.
It is critical that the data source for each core measure be valid, reliable, and standardized. Each data source has its challenges, however, and combined data sources currently are not widely available, limiting comparability. Yet the data used to populate measures must be both available and comparable, as data variations may incorrectly suggest variation in performance. Exclusion of behavioral health claims from insurers in one region, for example, would have a significant impact on total cost measurement and results. Obtaining a complete view of total cost requires access to the data needed to fully populate the measure set, and making a fair comparison across regions requires a consistent and standard approach to the inclusion of data elements.
Patient-reported data, typically gathered through periodic surveys, require a large number of surveys for an adequate sample size, a requirement that imposes considerable expense and administrative burden. Capturing data electronically may reduce the cost of surveying, but with the added risk of skewing the sample toward patients with access to and comfort with computers or other technology. Clinical data offer an optimal source of data for quality measurement but are difficult to obtain in an aggregated format. Current health information technology and electronic health records rarely enable interoperability, so that clinical data cannot always be shared or integrated across settings or over time. Moreover, access is limited by privacy and other concerns and assertions of ownership by individual organizations.
Claims data are the most readily available data, but health plans often place restrictions on data sharing and disclosure of data elements, making it difficult to access the data for community-wide or multipayer measurement initiatives. Several states have mandated the submission of claims data to all-payer claims databases to enhance access, and several regional health improvement collaboratives have gained voluntary support for data sharing, enabling system-wide and longitudinal measurement and reporting. Data that are effectively organized can both identify opportunities to reduce spending and support the development of payment reforms, enabling providers to capitalize on those opportunities.
An additional problem involves the use of individual versus pooled data by payers and providers, respectively. Typically, each physician and hospital receives information separately from each payer, resulting in an inherent decline in the quality of the data as the number of patients in any category will be smaller. Payers, on the other hand, typically pool their data, resulting in potentially higher reliability, but they use different definitions of the categories, different risk adjustment systems, and different comparison groups.
The more payers are generating these different reports, the more difficult it will be for health care providers to find the time to review and act on this information. Some national entities now are aggregating claims data from different payers, and several states have mandated submission of claims to all-payer claims databases to enable more comprehensive measurement. A growing number of communities have multi-stakeholder Regional Health Improvement Collaborative (RHIC) organizations that can combine claims data from all or most of the payers in the community and are capable of generating more robust analyses of spending, as well as payer-specific analyses in a common format. These emerging data sources will provide important resources for the use of a set of core measures, yet many barriers to consistent and comprehensive access to the data remain.
Data collection, aggregation, and management can be expensive and currently are not reimbursed. Given the specification, standardization, and analysis required, implementing new measures will require near-term financial and personnel investments. Resources will be required to configure data systems to capture the key data elements needed for the core measures. Additional resources will be necessary for clinical staff who must collect the data and enter them into the electronic health records, and further resources will be needed to update the data systems as measure specifications change over time. It will be important to consider these demands, as the feasibility of implementing the measure set will depend on the feasibility of implementing each component measure. Additionally, resources will be required to analyze the measures and apply that information toward improving health and health care. A transition period will be required to develop the skills and the technology needed to support the new measures. With performance measures typically being specified in multiyear contracts and tied to incentive payments, the transition will take time. On the other hand, the medium- and long-term savings can be substantial. The alignment and use of common measures not only can relieve provider burden but also reduce the waste of resources on redundant programs and accelerate improvement. Agreement by public and private purchasers on the use of the core measures for purchasing and accountability programs will streamline the effectiveness and efficiency of those efforts. As the return on investment for the use of core measures will not be immediate, realism is warranted as to time frames for implementation.
The process of standardizing data and improving sharing and access for widespread use requires engaging various legal and regulatory issues. As implementation of a core measure set includes the alignment of core measures with existing standards and regulations, the regulations may have to be changed to provide a common method for data definition and collection across the health system. Standards-setting organizations are therefore important partners in implementation of the core measures. Their standards can support a common measure set by ensuring that the necessary data elements are collected or by directly requiring their collection. In addition, various policies governing the collection, reporting, and use of health information must be engaged in the widespread application of a core measure set. One particularly important issue centers on privacy protections under the Health Insurance Portability and Accountability Act (HIPAA). Even though the constraints these protections place on data sharing may
be more a function of perception of the requirements than their content, the uncertainty involved contributes to variability in performance, and the assurance of data safeguards, where appropriate, will be important to the broad application and use of a core measure set. The penalties associated with data breaches may also contribute by encouraging conservative behavior by health care organizations.
As discussed previously, core measures present a relatively high-level view of health issues and outcomes, and therefore the measures included may not be equally relevant to all circumstances and stakeholder groups. Given the salience of the issues represented in the core measures, most health professionals will recognize the centrality of the measures to achieving their key goals and priorities. A specialist in allergy and immunology, for example, may not immediately find relevance in a core measure set that does not link explicitly to that specialty. On the other hand, progress in that arena is clearly dependent on widespread attention to such issues as well-being, community health, use of evidence-based practices, care match with patient goals, and individual and community engagement. Nonetheless, translation and emphasis will be important for the core measures to be recognized as vital elements in progress in all of health and health care.
In many cases, core measures may need to be translated for utility at different levels of aggregation. For example, while proportion of gross domestic product devoted to care provides a national view of health care spending, the concept of population spending burden also can be represented at the state, local, and institutional levels. At the state or local level, health care spending burden can be compared against overall budgets or economic output, or spending levels can be assessed relative to those in peer states or to a performance benchmark. At the level of health care institutions, the HealthPartners total cost of care and resource use measure can provide actionable information on spending in the context of providing care services.
The foundation of all successful implementation efforts is a strong sense of trust in the goals and potential benefits of the project or program. The core measures are intended to bring both local benefits to individual stakeholders and generalizable benefits to the health system at large. Making the case for adopting the core measures requires an approach that emphasizes confidence in these anticipated benefits and the expectation that they will outweigh any potential costs or challenges. Repeated, consistent
messaging in this regard will be key to building trust. An additional issue to be anticipated is the management of attribution—that is, the extent to which people or groups will be held accountable for any perceived successes or failures illustrated by the data resulting from application of the core measures. Health represents a complex measurement challenge; many factors contribute to measurement results, some of which may be beyond the health system’s direct control. For example, a hospital serving a low-income population would likely have lower scores on health outcome measures than would a hospital serving a relatively affluent population, although this differential may not reflect a disparity in the quality of care provided. The success of core measures and the interpretation of the data they produce will depend on a shared accountability view, such that results reflect on the system as a whole.
The success of the core measure set in driving progress throughout health and health care will depend not only on overcoming the challenges discussed above but also on strong and sustained leadership in continuous improvement of the set and each measure within it. Because many of the measures in the core set are limited to best current measures until more representative standardized alternatives are developed, that process needs to begin immediately. The process will need to involve multiple stakeholders in cooperative work, which in turn will require the necessary leadership capacities for governance, networking, and dissemination; measure standardization; technical assistance; evaluation of success; updating and retiring measures; and updating and amending the core measure set.
The Committee believes that the Secretary of HHS is the appropriate official to take on the leadership and governance roles required for successful stewardship of the core measures and their implementation and continuous improvement. It is the Secretary of HHS who directs the agencies most involved in the collection and use of health data; who signs off on reporting requirements and responsibilities; who is centrally positioned to convene and work with the key stakeholders; and who, as the leader most responsible for the nation’s effectiveness and efficiency in delivering better health at lower cost, has the greatest potential to ensure that the capabilities of the core measure set are realized. A schematic presented as Figure 5-2 identifies some of the primary needs and opportunities in that respect, including immediate introduction and use in federal programs and those of other stakeholders, as a pilot phase to gather information;
FIGURE 5-2 Schematic for HHS implementation of vital signs.
NOTE: HCO = health care organization; HHS = U.S. Department of Health and Human Services; WG = work groups.
development of a series of stakeholder working groups for each of the 15 measures, stewarded by HHS and charged with standardization and development of composites; then pilot testing and beginning the cycle of continuous improvement.
A first-order leadership opportunity lies in the Secretary’s ability to embed the use of the core measure set in the programs administered within HHS, as well as to help overcome the obstacles inherent in the many entities with vested interests in maintaining the varied measures and measure sets that suit their particular programs and priorities. Some entities design measurement and reporting products as part of their business model for a specific audience; some prefer particular measures for their internal improvement efforts; and product developers may prefer unique measure sets for market differentiation. As noted above, however, standardization, introduction, and use of the core measures as key components of and reference points for Meaningful Use, accountable care, the Medicaid waiver program, and even categorical health grant programs will contribute substantially
to system-wide capacity while also improving the productivity of the individual programs. In addition, leadership at the level of the HHS Secretary will be required to overcome the challenges described above that limit the alignment and application of the measures.
Standardization of the core measures is essential to enable greater awareness and understanding of the most critical issues facing the nation’s health system. The development, validation, and adoption of standardized measures will require the involvement of multiple stakeholders and experts in the issues addressed by the measures. A second key role requiring the active involvement and wielding of levers uniquely available to the Secretary of HHS, therefore, is engaging three early-stage measure application and refinement efforts, tailored to the demands of an evolving process: (1) developing guidance for the field on approaches to using best current measures in a fashion that will best advance the intent of the core set; (2) setting in motion the activities necessary to standardize the best current measures; and (3) planning and carrying out the process by which multi-stakeholder working groups will consider and develop the horizon measures for each of the core measure foci and determine how they will be implemented. Strong leadership will be needed to meet the formidable challenge of standardization. (Table 5-2 lists potential horizon measures for the core measure foci and example participants in their development.) To produce standardized and comparable measures of cost and value will likely require aggregation of claims data from multiple payers. Standardization of the data received from payers will, in turn, require attention to the data specifications, including such issues as the use of common definitions and the completeness of fields. Data currently are collected differently across programs, payers, and regions based on state policy, contracts, and privacy restrictions on certain data elements. But if communities seek to compare total cost and resource use across regions, for example, each data set will need to include and exclude the same elements—for instance, include substance use and behavioral health treatment data or exclude certain categories of outlier-cost patients—to avoid distortions in the results. Improved technical capabilities and the widespread availability of health information technology will be needed to enable the broad availability of integrated data sets. Resources, both human and financial, will be required to develop and maintain accurate methods for understanding provider relationships with patients, practices, and systems to enable attributed measurement and reporting.
TABLE 5-2 Example Horizon Indicators and Measure Development Participants
|Core Measure||Possible Horizon Indicators||Example Participants in Measure Developmenta|
|Life expectancy||Years of healthy life lost before age 80||
|Well-being||Physical, mental, emotional, and social well-being (composite index)||
|Overweight and obesity||Years of healthy life lost due to overweight and obesity||
|Addictive behavior||Health and social impact of all addictive behaviors (composite index)||
|Unintended pregnancy||Unintended pregnancy rate||
|Healthy communities||Environmental quality, green space, socioeconomic status, social capital (composite index)||
|Preventive services||Proportion of people receiving the full range of the U.S. Preventive Services Task Force’s recommended preventive services||
|Core Measure||Possible Horizon Indicators||Example Participants in Measure Developmenta|
|Care access||People reporting barriers to care||
|Patient safety||Patient safety events (composite index)||
|Evidence-based care||Proportion of care that is based on evidence (composite index)||
|Care match with patient goals||Patients reporting goal discussion and follow-up||
|Personal spending burden||Out-of-pocket health spending as share of income||
|Population spending burden||Total spending as a share of income or revenue in a specific population||
|Individual engagement||Involvement in self-care, family health, and community health (composite index)||
|Community engagement||Community focus/progress on health improvement (composite index)||
a Those listed are illustrative examples only from a large pool that also includes the various federal agencies with health measurement expertise and activities, as well as a commitment to ensuring the active participation of personal and professional stakeholders.
A third tool available to the Secretary of HHS for ensuring attainment of the potential of the core measure set is providing technical assistance to those working at other levels to assess how the core measures can best be incorporated into their institutional operations and work flows, the steps involved in aligning the capture of data to meet the needs of standardization, and the best ways to interface with other activities to maximize the utility of this work. With a ready regional capacity, as well as program leaders well established throughout the nation, the Secretary of HHS is well equipped to provide such technical assistance and the coordination that will be crucial to nationwide implementation of the core measure set.
If core measures are to lead to positive change, the performance measurement enterprise must both be part of a local system for change represented by a community health management system and capable of demonstrating contributions to accelerated progress toward better health at lower costs. At the community level, for example, several cities—such as Aurora, Colorado; Camden, New Jersey; and Kansas City, Missouri—have formed coalitions representing a comprehensive approach to health that have applied geocoding and other measurement strategies to design and implement population health initiatives. For instance, Kansas City targeted areas of the city where chronic health conditions, preventable infections, poverty, poor housing, and “food deserts” are concentrated. The city’s “bring health reform home” initiative includes strategies for addressing these socioeconomic inequities and improving access to care as well as economic security, including a recommendation to increase the minimum wage. At the state level, Oregon’s 16 regionally based community care organizations (CCOs) provide an example of an integrated health care and community health management system supported by an improvement and learning system. Each CCO is governed by a coalition of health care providers, consumers, local partners, and those organizations at financial risk.
Continuous learning requires adaptation as circumstances and opportunities change. Recent payment reforms are aimed at moving from a fee-for-service system that requires accounting-based measurement of individual services to a performance-based payment system emphasizing
value in health care. This shift offers a unique opportunity to test the ability of the core measure set to capture the utility of an outcome-based measurement approach that can reduce the amount and granularity of data collected—particularly claims data—by assessing care at the diagnosis, provider, or population level rather than at the level of individual services rendered. Although some process-related measurement will continue to be necessary for evaluation of organizational, group-specific practices, process measures will be eclipsed by core measures that more directly reflect health prospects. As the current administrative burden is alleviated by the transition from process- to outcome-based measurement, ongoing evaluation of the measures being employed at all levels of health care will be required.
Beyond the content of measures, systems will be needed to enable their improvement as underlying technological capabilities evolve. New technologies, particularly mobile technologies, may augment measurement capabilities and should be incorporated into routine practice as they become viable. For example, emerging new devices can continually measure specific aspects of an individual’s physical state, allowing a more complete picture of health status and the impact of various interventions. The expected flow of new data from these personal devices will have implications for what is measurable and actionable. These devices also will pose new challenges, such as their interoperability, the capabilities needed to analyze and use these new data, and the privacy and security of the data.
Although the best measures for many of the core measure foci have yet to be developed, the Committee believes the measures as a set stand as the vital signs of the nation’s health and health prospects. As times change, the content of the core set will need to change accordingly. An approach will therefore have to be developed for periodic reassessment of the content of the set. If the pragmatism of the principle of parsimony is a guide, and the Committee believes it should be, that reassessment process must be carefully designed and managed to guard against pressures to accommodate special causes. Specifically, all analysis, deliberations, and recommendations should be widely inclusive in process but completely independent of any particular stakeholder perspective in product. The often strongly expressed voices of various interests—economic, political, clinical, social, and otherwise—should be heard but should not overly influence outcomes. Care in structuring the eventual approach to updating and amending the core set, at such time as that activity is deemed appropriate, will be vital.
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