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December 05, 2014

National Quality Forum Begins Annual Review of Quality Measures, Comments Open December 23 on the 202 Proposed Measures

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On Monday, the Measure Applications Partnership (MAP) began its annual review of performance measures that the Centers for Medicare and Medicaid Services (CMS) is considering for use in 20 federal health programs. The 202 measures considered by the group have been made public (view the  PDF), and will be available for review and comment beginning December 23, 2014.

Established by the National Quality Forum (NQF) in 2011, MAP is a forum of approximately 150 healthcare leaders and experts, representing nearly 90 private-sector organizations. MAP comprises consumers, purchasers, labor, health plans, clinicians and providers, communities and states, suppliers, and liaisons from seven federal agencies.

“MAP brings the public and private sectors to consensus on how quality can be measured effectively and efficiently in federal health programs,” said NQF President and CEO Dr. Christine Cassel. “A key goal for MAP is to streamline the measures used by the federal government so that patients receive the quality care they deserve and providers can focus on how best to improve the care they deliver.”

What do some of these 202 new measures look like?

The measures included for review cut across a wide variety of treatments. Measures included on the list cover preventative care and a number of conditions, including diabetes, asthma, surgery, and cancer.

One measure, x4208, looks at opioid addiction. It seeks to quantify the percentage of patients with a diagnosis of current opioid addition who were counseled regarding psychosocial and pharmacologic treatment options for opioid addition within the 12 month reporting period.

Another, measure x3798, quantifies how often patients with diagnosis of a muscular dystrophy had a scoliosis evaluation ordered. Measure E0056 measures how many patients with diabetes received a foot exam during the measurement year. Another measure seeks to curb "unnecessary colonoscopies" in patients over age 86, when the risks apparently are reduced (X3769).

Some measures are extremely detailed. For example, x3773, entitled "Optimal Asthma Care," covers a wide range of required testing, tracking, and patient education protocols.

The list of applicable Federal programs (available on pg. 6-7 of the PDF) includes:

  • Ambulatory Surgical Center Quality Reporting Program;
  • End‐Stage Renal Disease (ESRD) Quality Incentive Program;
  • Home Health Quality Reporting Program;
  • Hospice Quality Reporting Program;
  • Hospital‐Acquired Condition Reduction Program;
  • Hospital Inpatient Quality Reporting Program;
  • Hospital Outpatient Quality Reporting Program;
  • Hospital Readmission Reduction Program;
  • Hospital Value‐Based Purchasing Program;
  • Inpatient Psychiatric Facility Quality Reporting Program;
  • Inpatient Rehabilitation Facility Quality Reporting Program;
  • Long‐Term Care Hospital Quality Reporting Program;
  • Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for Eligible Professionals;
  • Medicare and Medicaid EHR Incentive Programs for Eligible Hospitals or Critical Access Hospitals;
  • Medicare Shared Savings;
  • Medicare Physician Quality Reporting System;
  • Physician Compare;
  • Physician Feedback/Quality and Resource Utilization Reports;
  • Physician Value‐Based Payment Modifier Program;
  • Prospective Payment System‐Exempt Cancer Hospital Quality Reporting Program; and
  • Skilled Nursing Facility Value‐Based Purchasing Program.


Starting on p. 330, the pdf breaks down the CMS program that corresponds to each measure title.  

Download CMS List of Quality Measures

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CMS notes that they are issuing this list of measures to comply with Section 1890A(a)(2) of the Social Security Act, which requires the Department of Health and Human Services to make publicly available a list of certain categories of quality and efficiency measures that it is considering for adoption through rulemaking for the Medicare program. “Because this List contains measures that were suggested to us by the public, this List contains more measures than will ultimately be adopted by CMS for optional or mandatory reporting programs under Medicare,” states the report. “When organizations, such as physician specialty societies, request that CMS consider measures, CMS makes every effort to include those measures and make them available to the public so that [MAP], the multi‐stakeholder groups convened as required under 1890A of the Act, can provide their input on all potential measures.” 

The measures considered by the group are made public at the beginning of the forum and will be available for review and comment beginning December 23, 2014.

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