Will CMS’s New “Universal Foundation” Re-Vision Quality Measurement under Medicare?

Feb. 21, 2023
In a blog earlier this month, senior officials at the Centers for Medicare and Medicaid Services announced their determination to recreate quality outcomes measurement under Medicare

Earlier this month, several senior officials at the Centers for Medicare and Medicaid Services (CMS), including Elizabeth Fowler, Ph.D., J.D., Director of the Center for Medicare and Medicaid Innovation (CMMI), and CMS Deputy Administrator, made a significant announcement, published in the form of a blog in the “Perspective” section of The New England Journal of Medicine.

Entitled “Aligning Quality Measures Across CMS—The Universal Foundation,” the article, published online on Feb. 1, was written by Douglas B. Jacobs, M.D., M.P.H., Michelle Schreiber, M.D., Meena Seshamani, M.D., Ph.D., Daniel Tsai, B.A., Elizabeth Fowler, Ph.D., J.D., and Lee A. Fleisher, M.D. And it presaged what might be a new era in quality measurement under Medicare.

The authors begin their announcement-blog thus: “The quality-measurement movement began more than 20 years ago and has resulted in transparent quality-performance information, accountability, and improvements. At the same time, proliferation of quality measures has caused confusion, increased reporting burden, and misalignment of approaches for common clinical scenarios. The Centers for Medicare and Medicaid Services (CMS) and public–private partnerships have therefore moved toward creating more parsimonious sets of measures. Although some progress has been made, lack of alignment across CMS’s quality programs has contributed to challenges for clinicians, facilities, and health insurers when it comes to prioritizing outcomes that are meaningful for patients. We — the leaders of many CMS centers — aim to promote high-quality, safe, and equitable care. We believe aligning measures to focus provider attention and drive quality improvement and care transformation will catalyze efforts in this area. Since there is tension between measuring all important aspects of quality and reducing measure proliferation, we are proposing a move toward a building-block approach: a “universal foundation” of quality measures that will apply to as many CMS quality-rating and value-based care programs as possible, with additional measures added on, depending on the population or setting.”

In the blog, the CMS leaders acknowledge that, with CMS operating “more than 20 quality programs focused on individual clinicians, certain healthcare settings such as hospitals or skilled nursing facilities, health insurers, and value-based entities such as accountable care organizations,” there is a lack of consistency across settings. What’s more, they note, “Insurers often use the same quality measures as CMS (such as the Medicare Part C and D star ratings or plan-level measures for Medicaid managed-care organizations) to adjust clinician reimbursement as part of value-based arrangements — although some insurers use different or modified measures, which has also contributed to measure proliferation.”

It is in that context that the CMS officials announce in the blog that “The Universal Foundation is part of CMS’s efforts to implement the vision outlined in our National Quality Strategy1 and is fundamental to achieving several of the agency’s quality and value-based care goals.2,3 It is intended to focus providers’ attention on measures that are meaningful for the health of broad segments of the population; reduce provider burden by streamlining and aligning measures; advance equity with the use of measures that will help CMS recognize and track disparities in care among and within populations; aid the transition from manual reporting of quality measures to seamless, automatic digital reporting; and permit comparisons among various quality and value-based care programs, to help the agency better understand what drives quality improvement and what does not. To select measures for the Universal Foundation, CMS prioritized measures that were most likely to achieve these goals and have minimal unintended consequences (e.g., promoting overtreatment of certain conditions).”

Importantly, the CMS officials note that “Our intention is that the Universal Foundation will eventually include selected measures for assessing quality along a person’s care journey — from infancy to adulthood — and for important care events, such as pregnancy and end-of-life care. We started by identifying preliminary measures for the Universal Foundation’s adult and pediatric components (see table). The streamlined measures included here would be used across CMS programs and populations, to the extent that they are applicable and in keeping with legislative statutes.”

There certainly are going to many current obstacles that will have to be removed for this vision to become fully implemented over time; but what is significant here is that the future of quality outcomes measurement could potentially be fundamentally redirected through this initiative, as private payers would find it useful, beneficial, and above all, practical, to follow CMS’s lead, once this Universal Foundation can be fully implemented.

Another element in this is that the senior CMS officials are looking to connect this Universal Foundation to their previously stated overall strategic goals. They write that “For organizations that develop and endorse quality measures, the Universal Foundation will identify CMS’s priority areas for measurement and reveal gaps. For example, although patient safety is a top priority for CMS and there are several well-developed safety measures used in hospitals, there is no patient-safety measure that is widely used in ambulatory settings. Another current gap is the lack of a measure of holistic well-being. The Universal Foundation will continue to evolve over time; as quality measurement improves or when quality goals within a category are met, CMS will consider replacing or removing measures. We also intend to move toward using more outcome and patient-reported measures and measures for which data can be collected and reported digitally.”

And I think that that is an absolutely key element here, as CMS officials under the Biden administration have gone further than those under any previous administration towards laying out defining principles and key strategic policy goals. And it is the policy clarity that they bring to this effort that could potentially help it succeed and, if it succeeds, revolutionize clinical quality outcomes measurement in U.S. healthcare.

And the CMS officials are very aware of that, concluding their announcement-blog by writing that “We believe that, by focusing providers’ attention, the Universal Foundation will result in higher-quality care for the more than 150 million Americans covered by our programs. But quality-measure alignment is just the first step; we cannot accomplish the enormous task of quality improvement and care transformation without a concerted effort among clinicians, provider organizations, insurers, community-based organizations, state and local governments, and patients. We hope that alignment focused on the Universal Foundation within CMS can also set the stage for alignment throughout the health care system, with improved outcomes being our collective North Star.”

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