CMS Teams With ACC to Make Quality Measures More Relevant

Debra L. Beck

August 28, 2020

The Centers for Medicare & Medicaid Services (CMS) has partnered with the American College of Cardiology (ACC) to include several National Cardiovascular Data Registry (NCDR) measures as part of their Alternate Quality Measures Set.

Not only can NCDR measures now do double duty, but for sites that opt in to using these alternative measures, the ACC itself will be submitting the data directly to CMS, reducing reporting burden on NCDR sites.

"There was feedback from the clinician community that the measures weren't clinically specific," said Christine Perez, JD, the director of Payer & Care Delivery Policy at the ACC.

"So, for example, if you had an episode around percutaneous coronary intervention [PCI], the kind of the measures that CMS automatically assigned were broader outcomes like all-cause hospital readmission, so the feedback was that those broader measurements capture performance across the whole hospital, but they don't really drill down to the actionable areas of improvement for a specific episode of care," she added.

It's a natural move for the ACC to get involved in quality measure reporting, said Perez. "The ACC has decided to be more proactive in this move to value-based care and to help inform future payment models for cardiology and mold what best serves patients and clinicians, rather than just addressing what comes from CMS through the rulemaking process."

"The NCDR registries capture measures that the doctors stand behind and consider important indicators of quality," she added.

The changes are part of a 2-year effort announced August 18 when CMS released quality measure sets for Model Year 4 of the Bundled Payments for Care Improvement (BPCI) Advanced program, which qualifies as an Advanced Alternative Payment Model under the Quality Payment Program.

Under the program, participants can continue to report the Administrative Quality Measures Set or a new Alternate Quality Measures Set.

According to an ACC news story, current BPCI Advanced participants will receive further information from CMS regarding deadlines for episode and measure set selection through their BPCI Participant Portal.

New Reporting Options

The NCDR CathPCI Registry, Chest Pain – MI Registry, and ICD Registry are now approved reporting options for participants using the new Alternative Quality Measure Set for acute myocardial infarction (AMI), cardiac defibrillator, and percutaneous coronary intervention (PCI).

In addition to the claims-based All-Cause Hospital Readmission and Advanced Care Plan measures that will be collected for all BPCI Advanced episodes, the new measure set includes the following episode-specific measures:  

Acute Myocardial Infarction (AMI)

  • 3-Item Care Transition Measure (NQF #0228)*

  • Overall Defect Free Care (NQF #2377), as currently reported in the Chest Pain – MI Registry


Cardiac Defibrillator (Inpatient or Outpatient)

  • 3-Item Care Transition Measure (NQF #0228)*

  • Discharge Medications: Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker and Beta-Blockers in Eligible Implantable Cardioverter-Defibrillator Implant Patients (Composite Measure) (NQF #0965), as currently reported in the ICD Registry

  • Hospital Risk-Standardized Complication Rate following Implantation of Implantable Cardioverter-Defibrillator, as currently reported in the ICD Registry


Percutaneous Coronary Intervention (PCI) (Inpatient or Outpatient)

  • Cardiac Rehabilitation Patient Referral from an Inpatient Setting (NQF #0642), as currently reported in the CathPCI Registry

  • In-hospital Risk Adjusted Rate of Bleeding Events for Patients Undergoing PCI (NQF #2459), as currently reported in the CathPCI Registry

  • Therapy with Aspirin, P2Y12 Inhibitor, and Statin at Discharge following PCI in Eligible Patients (NQF #0964), as currently reported in the CathPCI Registry

*This measure will be derived from IQR performance, not registry performance.


Ravi Hira, MD, associate professor at the University of Washington in Seattle and medical director of the Cardiac Care Outcomes Assessment Program in Washington state, applauded the move. "I think there is a need to include clinical and process measures to evaluate and improve quality, rather than just focusing on these downstream hard outcomes, which among other things can promote risk aversion and gaming the system," he told | Medscape Cardiology.

He only hopes this is just the beginning of a process of continual quality improvement. "Once the vast majority of sites meet these bare minimum requirements, like providing appropriate therapies on discharge after PCI, I hope we can push the bar a bit more and make sure people are constantly moving toward improvement."

He suggested, for example, including radial artery access in ST-segment elevation MI into the measure set in the future.

"Once you've figured out how to make these measures standard, maybe by reimbursing sites at a higher rate for meeting them, I think that the benefits that are potentially passed on to patients may erode a little bit, so I hope they will then add in some other measures to set up a process for constant improvement."

A frequent critic of CMS quality reporting measures, Rishi Wadhera, MD,  MSc, Beth Israel Deaconess Medical Center, Boston, noted in an email exchange with | Medscape Cardiology that given the amount of time and money needed to fulfill performance reporting requirements, and concerns regarding unintended consequences of reporting, this move is welcomed.

"Efforts like this — to make quality reporting more seamless and less burdensome — are critically important," said Wadhera.

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