The Centers for Medicare and Medicaid Services (CMS) quality measures inspire both hope and dread in the providers who must adhere to them. After all, how well they adhere impacts their funding.
CMS quality measures help quantify health care processes, outcomes, patient perceptions, organizational structure and system goals. The goals related to these include care that’s effective, safe, efficient, patient-centric, equitable and timely. With such a broad reach, these metrics can often live in silos.
These initiatives have been a priority for CMS, demonstrated by the fact that the organization spent $1.3 billion on the development of the initiatives between 2008 and 2018. In turn, providers have spent $15.4 billion annually to report them. The time required is just as extensive, totaling 785 hours per year per provider.
Even with these investments of time and money, providers still wonder if the measures improve care. That would seemingly signal time for reform as a result of not seeing noticeable improvements in care.
As a Medicare plan, you’re not responsible for reporting these measures, but they still impact plan decision-making for providers. As such, the trends affecting these measures — including the pandemic, digitization, payment models and social determinants of health (SDOH) — are vital to your members and their health.
Health care quality measure reporting burden lessened in 2020.
In 2020, CMS realized reporting was too much of a burden for a country in the throes of a pandemic. Health care was in chaos, so CMS made reporting optional for the first part of 2020. However, it did bring reporting back for the second half of 2020 with some adjustments. CMS also established a rule related to measure suppressions and payments if data showed a “significant impact from COVID-19.”
Although there is only partial data for 2020, CMS did release a report for the year. Here is some data to note:
- 46 percent of measures addressed outcomes or costs.
- 80 percent of measures were in digital format.
- There were 686 total measures.
The agency concluded that measures work to improve quality and reduce costs. The findings from 2020 are also fueling the change that became ignited during the pandemic.
The pandemic exposed cracks in quality measures.
With clinicians stretched to the max, the pandemic allotted little time for the arduous reporting required by CMS. Clinicians could not spend hours on documentation after treating patients all day. They received a reprieve in 2020, but continued to push back against CMS on the effectiveness of certain measures.
Of the three sets of measures — structural, process and outcomes — the latter seems the most influential on care. CMS has acknowledged the need for reform, concentrating on outcomes. The agency is working on changes that will:
- Focus on prioritizing outcomes.
- Use only high-quality measures that impact key quality domains.
- Align measures with value-based programs and across all partners (CMS, federal entities and private entities).
- Make measures completely digital.
- Incorporate lessons learned from the pandemic.
- Develop and implement measures that reflect SDOH.
These CMS priorities are illustrative of existing and emerging trends.
The pandemic highlighted the need for real-time data and digitization.
Health care has been on a digital transformation journey since the deployment of electronic health records (EHRs). However, full adoption across the ecosystem still isn’t 100 percent, and the industry struggles with interoperability and data sharing.
The pandemic compounded these challenges and emphasized the need for more real-time data for better decision-making. Medicare plans would benefit from this because if treatment improves, costs go down. Better outcomes for members mean better usage of the health care system.
CMS’s plan for complete digitization by 2025 will reduce the administrative burden of reporting. All that valuable data could be essential for the future of health care in the United States.
Performance doesn’t correlate to improvements in care.
Because quality measure performance affects payment models, providers are incentivized to participate. However, this means they will focus on what they do well to get the credit. This leads to more difficult measures not receiving the attention they deserve, proving that performing well on certain quality measures doesn’t necessarily correlate to improved care.
Most physicians want to deliver better care and improve across all measures. The framework to develop this is very rigid. As a result, the system rewards providers for high marks, even if they don’t achieve better outcomes or reduced costs.
Quality measures should close health care equity gaps.
Health equity is a consistent problem, impacting many Medicare members. The pandemic only worsened this issue. CMS now has a renewed focus on quality measures and their impact on payment models. This strategic review is an effort to bridge equity gaps.
CMS asked for feedback on quality measures related to equity challenges regarding race, ethnicity and other factors. To achieve better access to care, addressing SDOH is critical and on the board for reform.
Quality measures should address SDOH.
Quality measure reforms will involve addressing social determinants of health (SDOH). SDOH are relevant for the average Medicare member due to their age, access to transportation, economic status and even access to food.
CMS expanded coverage for Medicare Advantage (MA) plans to help address these SDOH. Before this change, a member had to meet three components. Now, a member has to meet only one of four criteria to qualify.
With those guidelines in place, NORC at the University of Chicago conducted a study to measure Medicare Advantage’s performance in aiding SDOH challenges. First, the researchers identified that 52.7 percent of MA members live below 200% of the federal poverty level, and 33.7 percent identify as minorities.
The report concluded that MA plans increased their activity in addressing SDOH, but it noted that there is room for more interventions. There are still many social needs outside of the health care system, including complex challenges that may not necessarily have a treatment plan but are detrimental to physical and mental health. One condition that represents this need and ties directly to SDOH is loneliness.
Treating loneliness could be a meaningful quality measure.
Quality measures have the primary objective of improvement in all areas. A lean toward care tactics outside of traditional options could provide the improvements that all Medicare stakeholders seek. One of these tactics could be evidence-based interventions for those that are chronically lonely. The science of loneliness is expanding, and Medicare plans are embracing it with solutions that infuse technology with human interaction.
Pyx Health provides an app to measure loneliness and its causes. However, that’s just the first tier. The most important element is the team of friendly staff that speak to members on the phone for as long and as often as they like. These new friends listen without judgment and help your members navigate their health care. The app also helps identify and resolve SDOH needs and provides actionable member data to health plans.
When you address loneliness, you can see improvements in member engagement and participation. You can offer solutions to care for the whole person and alleviate SDOH concerns.
Learn more about our proven solutions and strategies to treat chronic loneliness for Medicare plans.
