"The two words ‘information’ and ‘communication’ are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through." -- Sydney J. Harris

Improving Health Care Quality through Measure Development, Evolution and Alignment

MNCM_10thAnnivLogo_RibbonOnly_FNLPhysicians are faced with an unprecedented number of quality measures required by different entities in today’s health care system. Payment is pivoting away from traditional reimbursement models and moving toward value-based reimbursement, where value factors in both quality and cost. Patients are slowly moving from being passive receivers of health care to informed consumers with expectations of transparency. And payers and employer groups are demanding more accountability for how their dollars are spent on care. In this changing environment, health care quality measurement must also evolve.

The National Quality Forum (NQF), a non-profit organization in Washington, DC, plays an important role in standardizing health care quality measurement across the country and recommending measures for use in Medicare value-based purchasing and meaningful use programs. MNCM’s President, Jim Chase, has served on the NQF Board of Directors since January 2014, where he’s been able to share MNCM’s practical experience in both measure development and data collection.

Minnesota tops the nation in many health care surveys, so it’s no surprise that we’re well positioned to take advantage of – and even drive – national and local activities in quality measurement and value-based purchasing. We are actively working to align local and national measurement work through high-value measurement that drives real improvement in cost, quality and patient experience of care.

“There are many exciting opportunities and partnerships that remind us that while Minnesota is at the forefront of health care measurement and improvement, we must also continue to push ourselves so our community and nation ultimately achieves the goal of delivering the highest quality care with the best patient experience for the most efficient cost,” said Jim Chase, MNCM President.

Develop, Refine and Test Measures

MNCM is well versed in measure development, testing and endorsement. Since 2003, we have collected, analyzed and reported health care information. We currently publicly report on more than 70 cost, quality and patient experience measures, with numerous measures in development. 

During this time, we’ve refined our measurement development process to provide:

  • Innovative, evidence-based measure creation and refinement
  • Creation of detailed, feasible specifications for data collection and implementation
  • Diverse data sets to draw from for testing
  • Robust piloting that incorporates key stakeholders
  • Expertise in working with data from disparate sources
  • Credibility to move measures through to acceptance

Refined Measure Development Process

We’ve spent years fine tuning our process to make it as efficient as possible. Each stage of our standard process has been thoroughly tested, and includes a variety of stakeholders who help to build robust measures. The general stages of our measure development process take a measure from initial concept through implementation and reporting.

Life Cycle GraphicOnce the initial implementation results are validated, they can by publicly reported. MNCM publishes the measure rates in our annual Health Care Quality Report, our annual Disparities Report, and on Health care providers can use the data in quality improvement efforts. Patients can identify how well their clinic is performing, and use the data to talk with or choose providers. Employers and health plans can use the information in pay-for-performance programs. And researchers and policy makers can use it to determine how to improve the health of our state.

Measure Review and Refinement

Ongoing evaluation of existing measures is necessary to ensure continued value to the community. The principles of measure evaluation criteria that are applicable during measure development hold through the review and maintenance of a measure as well. Criteria for determining the value of a measure must include (i.e., all four criteria must be met):

  1. Consistency with evidence-based standards of care and guidelines
  2. Whether it addresses a high-priority aspect of health care (e.g., high disease burden, high resource use, severity of illness)
  3. Whether it demonstrates a gap in performance across providers
  4. Reliability and validity

Additional criteria for consideration includes feasibility and burden; current use of the measure in existing accountability and/or quality improvement programs; and how well it aligns with existing local and national measurement programs.

MNCM conducts validity testing to determine if each measure truly evaluates what it is designed to measure. In other words, if the measure, as specified, accurately assesses the intended concept behind the measure that reflects the quality of care that is provided to a patient. MNCM also performs reliability testing to determine if the measure yields stable, consistent results. In other words, if the measure is reproducible.

Alignment of National and State Reporting

Over the past five years, MNCM has been increasingly successful in getting measures developed in Minnesota adopted by the Centers for Medicare and Medicaid Services (CMS) for their Physician MeasureAlignment GraphicQuality Reporting System (PQRS), Meaningful Use and Accountable Care Organization (ACO) Shared Savings programs. Most recently, our Optimal Asthma Control and Depression Remission at 12 Months measures were newly added for 2015, where they join multiple previously-adopted measures.

MNCM works diligently to develop high-quality measures that are widely applicable so they can be adopted by multiple local and national organizations, which drives to alignment. In fact, of the 33 MNCM ambulatory care measures that were publicly reported by MNCM in 2014, 29 (88 percent) are aligned with at least one state, federal or pay-for-performance program and 64 percent are aligned with at least two programs.

MNCM works hard to get our measures accepted by state and federal reporting and incentive programs to further this alignment.

Seven of MNCM’s measures are endorsed by NQF, making them more likely to be adopted by federal reporting programs. The seven measures currently endorsed are:

  • Optimal Diabetes Care
  • Optimal Vascular Care
  • Depression Response – Six and 12 Months
  • Depression Remission – Six and 12 Months
  • Depression – PHQ-9 Utilization

We also have early indications that several new MNCM measures will be endorsed by NQF later this year.

In addition, MNCM has worked to get our measures utilized by pay-for-performance programs, such as Minnesota Bridges to Excellence (MN BTE) and the State of Minnesota’s Quality Incentive Payment System (QIPS). We put measures through a rigorous process before they are submitted for endorsement or inclusion in any programs. Our guiding principles are that, in order to be of the highest value, measures should be meaningful; evidence-based; actionable; credible; feasible; aligned with the community; and reflect opportunity for improvement.

Continuously Evolving Measures

Ongoing evaluation of existing measures is necessary to ensure continued value to the community. In 2014, MNCM strengthened its measure review and maintenance process in three key ways:

  1. Adoption of a new measure review process that includes four levels of increasingly intensive review, research, assessment and redesign.
  2.  Formation of the Measure Review Committee, a sub-committee of the Measurement and Reporting Committee (MARC), responsible for annual measure review and maintenance activities.
  3. Creation of a strategic measurement framework, a tool to guide the identification of gaps in the measurement landscape and guide priorities for new measure concepts. The framework is based on the three aims of the National Quality Strategy and the six domains of quality as defined by the Institute of Medicine.

Measurement must be based on evidence that supports the process or outcome being measured for the population. When health care guidelines change or new evidence becomes available, the test for evidence must be reexamined. Any necessary changes have to be thoughtfully planned and implemented.

This was reflected recently when guidelines for the management of cholesterol changed, which affected our Optimal Diabetes and Vascular Care measures. MNCM convened a workgroup to determine the new guidelines’ impact on the diabetes and vascular measure. The workgroup presented a redesigned cholesterol component, which aligned with the new guidance; the redesigned component will be part of the Optimal Diabetes and Vascular Care measures beginning in report year 2016.

Accelerating the Improvement of Health

We are continuously looking ahead to seek new ways to improve health by providing quality, cost and patient experience in high-impact areas where measurement is lacking. We seek to improve and maintain the existing measurement landscape so reliable information is available to guide decision makers, inform medical group quality improvement efforts and support patients’ health care choices. As quality gaps diminish and overall performance improves, we are mindful of the appropriate retirement of measures, which minimizes the burden on the health care system.

We are also increasingly becoming a vehicle for other measure stewards to test their newly-developed quality measures. In 2014, MNCM developed the Measures Lab, an online platform to efficiently test newly-developed quality measures. The Measures Lab facilitates testing the feasibility, reliability and validity of new measures before they are submitted for endorsement; proposed for inclusion in federal programs; or implemented to support quality improvement efforts.