CMS Allocated $1.3 Billion to Quality Measure Development Over 10 Years

Debra L Beck

May 13, 2020

Between 2008 and 2018, the Centers for Medicare & Medicaid Services (CMS) invested more than $1.3 billion to develop and maintain quality measures to be used to promote healthcare quality and quality improvement.

This bounty has resulted in the development of a portfolio of 2266 quality measures, of which only 788 measures (or 34.8%) have been implemented or finalized for use in a CMS program to date, according to a just published review of publicly available sources.

"As the US moves toward value-based payment, CMS has led efforts to improve quality of healthcare. In doing so, CMS has also unintentionally created a 'quality-industrial complex' for measure development, implementation, and reporting," said lead author Rishi Wadhera, MD, MSc, Beth Israel Deaconess Medical Center, Boston. 

"We don't know if, at least in recent years, this complex has actually improved our patients' quality of life and health. We do know that quality documentation and reporting have increased costs and administrative burden to clinicians, and impeded their ability to focus solely on doing what is best for their patients."

Wadhera and colleagues published the findings of their review as a Research Letter April 28 in JAMA.

"It's worth emphasizing that the $1.3 billion reflects what has been spent only on quality measure development. It doesn't include the additional costs for CMS to roll out and implement these measures in national quality programs, the costs imposed on hospitals and practices to develop the infrastructure and hire administrators to report these measures to CMS, nor any ancillary costs incurred to meet measure requirements, such as hiring consulting firms to help providers navigate performance and reporting."

The evidence to date suggests that many federal value-based programs that link CMS quality measures to reimbursement have met with limited success. The Affordable Care Act's Hospital Value-Based Purchasing (HVBP) program, for example, appears not to have improved patient outcomes.

And recent study has suggested that the implementation of the Hospital Readmissions Reduction Program (HRRP) might be associated with increased mortality among patients admitted with heart failure and pneumonia. Other studies, however, including a recent one by the Medicare Payment Advisory Commission (MedPAC), a nonpartisan legislative branch agency that advises Congress on Medicare issues, found no such link.

Of the 3129 hospitals evaluated in the HRRP program for fiscal year 2019, 83% received a penalty, which will be deducted from the current fiscal year. Medicare estimates that this latest round of penalties will cost hospitals $563 million over a year.

Some measures, like many of the components of Medicare's Merit-based Incentive Payment System (MIPS), have not only been shown not to improve patient care, but may even increase potential risks for older patients.

"CMS needs to do more to ensure that their quality measures are valid and meaningful. They have fallen behind on rigorously evaluating how these measures affect patient care and outcomes once they're rolled out into the real world," said Wadhera.

The measures data come from the publicly available CMS Measure Inventory Tool (CMIT) and the spending data were pulled from and adjusted for inflation.

Quality measures not in use are either still in development or under consideration (738 measures) or are not in use because they have not been implemented or finalized for use or have been removed or not accepted by a CMS program (740 measures).

The measures — most of which focused on processes or outcomes — are currently in use in 34 CMS programs, like the HRRP, MIPS, and the Hospital Inpatient Quality Reporting Program.

Some programs, like the HRRP, include relatively few measures, according to Wadhera, whereas others, like the outpatient Quality Payment Program, include "hundreds" of measures.

Top Five Awardees Received $872.9 Million

The total inflation-adjusted amount of money awarded by CMS between 2008 and 2018 to develop and maintain quality measures was $1,313,500,000. In their letter, Wadhera and colleagues note that, in total, 35 organizations received award contracts, with most of the money — $872.9 million — awarded to just five organizations.

Publicly available data from reveals more details: The Yale Center for Outcomes Research and Evaluation (CORE) has been awarded the most in contracts, receiving 19% of all awarded monies, or $246 million over 10 years. After Yale, Mathematica has received $217 million, Acumen Physician Solutions has received $150 million, Health Services Advisory Group has received $124 million, and RTI International has received $85 million.

"These organizations have significant influence over CMS's quality agenda. With such large amounts of money at stake, there may be a financial and intellectual incentive to keep producing more quality measures," said Wadhera.

In response to an interview request, Harlan Krumholz, MD, SM, director of CORE, emailed the following comments:

"In our experience, CMS seeks to balance the need for performance measures to promote accountability, stimulate improvement, and incentivize attention to quality. Each of our measures builds on input from clinicians, methodologists, and patients — and goes through many cycles of evaluation."

"The public reporting of measures and their integration into incentive programs has represented an important advance in American medicine. In the next stages, we have opportunities to improve the way measures are developed — and the fidelity of the measures that are produced. I can't speak for all the measures, but what our group has done in partnership with CMS has, in many cases, been transformative for patient care."

"If anything, I think the investment in assays of health system performance — and their linkage with efforts to improve care — need to be augmented," Krumholz added.

Mathematica did not respond to a request for comment.

Cancelled for COVID

Ironically, right now all this effort and expense is for naught because CMS has suspended the majority of their quality measurement programs to provide hospitals with "unprecedented relief" from the burden of data reporting during the COVID-19 crisis.

In March, providers and hospital systems were informed that they no longer need to submit data to the HRRP, the Ambulatory Surgical Center Quality Reporting Program, the End-Stage Renal Disease Quality Incentive Program, and the Hospital Inpatient Quality Reporting Program, among others.

"This is being done to reduce the data collection and reporting burden on providers responding to the COVID-19 pandemic," according to a late March press release from CMS.

An April 18 press release announced "flexibility" for Qualified Health Plan (QHP) issuers.

Wadhera is pleased to see these announcements. "This will allow administrators who are responsible for collecting these data and reporting them to CMS to focus their attention on more meaningful tasks, such as ensuring their front-line staff are adequately protected and have enough resources to care of the surge of COVID-19 patients," he said.

Wadhera reports receiving research support from the National Heart, Lung, and Blood Institute, and previously serving as a consultant for Regeneron. As stated, Krumholz is the director of CORE, which receives money from CMS to develop and maintain quality measures.

JAMA. 2020;323:1614-1616. Research Letter


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