Quality Resource Center

Increasing Patient-Community Capacity to Engage on Quality of Health Care Research

Glossary of Acronyms

Quality Related Acronyms 

ACL – Administration for Community Living

AHRQ – Agency for Healthcare Research and Quality

AMA – American Medical Association

APMs – Advanced Alternative Payment Models

ACSO QOPI – American Society for Clinical Oncology – Quality Oncology Practice Initiative

CDC – Centers for Disease Control and Prevention

CMS – Centers for Medicare & Medicaid Services

EBM – Evidence Based Medicine

FDA – Food and Drug Administration

HRSA – Health Resources and Services Administration

IHI – Institute for Healthcare Improvement

IOM – Institute of Medicine

MACRA – Medicare Access & CHIP Reauthorization Act

MAP – Measures Application Partnership

MIPS – Merit-based Incentive Payment System

MMS – Measurement Management System

NPP – National Priorities Partnership 

NCQA – National Committee for Quality Assurance

NQF – National Quality Forum

NQS – National Quality Strategy

Joint Commission – The Joint Commission: Accreditation, Health Care, Certification

P4P – Pay for Performance

PCPI – Physician Consortium for Performance Improvement (PCPI)

PPACA or ACA – Patient Protection and Affordable Care Act

PQA – Pharmacy Quality Alliance

PQRS – Physician Quality Reporting System

SAMHSA – Substance Abuse and Mental Health Services Administration

QPP – Quality Payment Program

URAC – Utilization Review Accreditation Commission

 

Increasing Patient-Community Capacity to Engage on Quality of Health Care Research

References

Module 1: The Changing Health Care Environment & the Role of Quality

Institute of Medicine. (2001). Crossing the quality chasm. A new health system for the 21st century. Washington, DC: National Academy Press.

Kohn LT, Corrigan JM, & Donaldson MS (Eds.). (2000). To err is human. Building a safer health system. Washington, DC: National Academy Press.

Medicare. (2017). Hospital Compare. Accessed May 2017 at https://www.medicare.gov/hospitalcompare/search.html.

National Priorities Partnership. (2011). Input to the Secretary of Health and Human Services:  Priorities for the National Quality Strategy.

“National Quality Strategy Stakeholder Toolkit.” Agency for Healthcare Research and Quality. March, 2016. Available at https://www.ahrq.gov/workingforquality/nqs-tools/national-quality-strategy-stakeholder-tool-kit.html#nqsfact

NQC Quality Academy: What is QI? – The NQC Quality Academy is a set of 20 minute presentations designed to give people a crash course on any given topic related to clinical quality management. http://nationalqualitycenter.org/nqc-activities/qualityacademy/quality-academy-links/

Physician Compare. Medicare. (2017). Physician Compare. Accessed May 2017 at https://www.medicare.gov/physiciancompare/.

Slide Set: National Quality Strategy Overview. Content last reviewed January 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/workingforquality/nqs-tools/briefing-slides.html

Module 2: Why Quality Matters For Patients?

Agency for Healthcare Research and Quality. (2017). Strategy 6I: Shared Decisionmaking. Accessed May 2017 at https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6i-shared-decisionmaking.html.

Anderson M, Schneeman K. How Patient Groups Have Begun To Influence The Value And Coverage Debate. Health Affairs. http://healthaffairs.org/blog/2016/06/10/how-patient-groups-have-begun-to-influence-the-value-and-coverage-debate/. Accessed May 2017.

Module 3: Everything You Wanted to Know About Quality, But Were Too Afraid To Ask

National Quality Forum, Glossary of Terms (2015). Accessed at: https://www.qualityforum.org/Measuring_Performance/Submitting_Standards/NQF_Glossary.aspx

Phrase book. National Quality Forum. Available at http://public.qualityforum.org/NQFDocuments/Phrasebook.pdf. Accessed May 2017.

Module 4: Where Do Quality Measures Come From?              

 

Agency for Healthcare Research and Quality. (2015). Types of Quality Measures. Accessed May 2017 at:

https://cahps.ahrq.gov/consumer-reporting/talkingquality/create/types.html

Center for Medicare & Medicaid Services. (2015). Quality Measures. Accessed May 2017 at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html?redirect=/qualitymeasures/03_electronicspecifications.asp.

Module 5: The Role of Quality in Value-Based Payment

Centers for Medicare & Medicaid Services. MACRA, Delivery System Reform, Medicare Payment Reform. Accessed at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html

Doctors Earn More Than $148 Million in Quality of Care Bonus Payments for Improving Health Outcomes, Addressing Care Opportunities for UnitedHealthcare Medicare Advantage Members. United Healthcare website. https://www.uhc.com/news-room/2016-news-release-archive/quality-of-care-bonus-payments. Published August 4, 2016. Accessed May 2017.

Frank J. Gold Star Program to be Replaced with New Quality Rewards Program [letter]. United Healthcare. http://www.uhccommunityplan.com/content/dam/communityplan/healthcareprofessionals/providerinformation/PA-Provider-Information/PA_2015_Gold_Star_Retirement.pdf. Accessed May 2017.

The official U.S. government site for Medicare. How do Medicare Advantage Plans work? https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/how-medicare-advantage-plans-work.html. Accessed May 2017.

Leonard D. The Health Care Paradigm Shift: Moving from Volume to Value. Morning Consult. March 31, 2015. https://morningconsult.com/opinions/the-health-care-paradigm-shift-moving-from-volume-to-value/. Accessed May 2017.

Slide Set: Quality Payment Program. Centers for Medicare and Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-Quality-Payment-Program-webinar-slides-10-26-16.pdf. Accessed March 23, 2017.

The official U.S. government site for Medicare. Star Ratings. https://www.medicare.gov/find-a-plan/staticpages/rating/planrating-help.aspx. Accessed May 2017.

Doctors Earn More Than $148 Million in Quality of Care Bonus Payments for Improving Health Outcomes, Addressing Care Opportunities for UnitedHealthcare Medicare Advantage Members. United Healthcare website. https://www.uhc.com/news-room/2016-news-release-archive/quality-of-care-bonus-payments. Published August 4, 2016. Accessed May 2017.

Module 6: Turning What We’ve Learned into Practice

Slide Set: National Quality Strategy Overview. Content last reviewed January 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/workingforquality/nqs-tools/briefing-slides.html

Other Helpful Quality Resources

Chassin MR, Loeb JM. The ongoing quality improvement journey: Next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-568. doi: 10.1377/hlthaff.2011.0076 [doi].

Institute of Medicine (IOM). To err is human: Building a safer health system. . 2000.

Institute of Medicine (IOM). Crossing the quality chasm: A new health system for the 21st century. .

Health policy briefs: Pay-for-performance october 11, 2012. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78.  Accessed 04/08, 2016.

American Medical Association (AMA). 2015 physician quality reporting system. http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system.page.  Accessed 04/08, 2016.

National Quality Forum. The ABC’s of measurement. http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx. Accessed 2016, 04/08.

Centers for Medicare and Medicaid Services (CMS). Core measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures.html. Accessed 04/08, 2016.

McClellan M. Testimony to U.S. senate committee on finance on june 26, 2013: Improving health care quality: The path forward.. 2013.

Sofaer S, Crofton C, Goldstein E, Hoy E, Crabb J. What do consumers want to know about the quality of care in hospitals? Health Serv Res. 2005;40(6 Pt 2):2018-2036. doi: HESR473 [pii].

Ranard BL, Werner RM, Antanavicius T, et al. Yelp reviews of hospital care can supplement and inform traditional surveys of the patient experience of care. Health Aff. 2016;35(4):697-705. http://content.healthaffairs.org/content/35/4/697.abstract.

Transcript of remarks by carolyn clancy, MD, measuring health care quality (washington: Kaiser family foundation, 2008). http://kff.org/interactive/measuring-health-care-quality-tutorial/. Accessed 03/30, 2016.

Woolf SH, Zimmerman E, Haley A, Krist AH. Authentic engagement of patients and communities can transform research, practice, and policy. Health Aff. 2016;35(4):590-594. http://content.healthaffairs.org/content/35/4/590.abstract.

Hibbard JH. Engaging health care consumers to improve the quality of care. Med Care. 2003;41(1):I61-I70. http://www.jstor.org.proxy-hs.researchport.umd.edu/stable/3767729.

National Quality Forum. Patient and family engagement action pathway. http://www.qualityforum.org/Publications/2014/07/Patient_and_Family_Engagement_Action_Pathway.aspx.  Accessed 04/11, 2016.

Academy Health. Improving quality health care: The role of consumer engagement. https://academyhealth.org/files/issues/ConsumerEngagement.pdf.  Accessed 04/11, 2016.

Agency for Healthcare Research and Quality (AHRQ). Strategy 1: Working with patients and families as advisors. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy1/index.html. Accessed 03/30, 2016.

Boivin A, Lehoux P, Burgers J, Grol R. What are the key ingredients for effective public involvement in health care improvement and policy decisions? A randomized trial process evaluation. Milbank Q. 2014;92(2):319-350. doi: 10.1111/1468-0009.12060 [doi].

National Quality Center. Quality improvement resources – helpful tools to assist in your quality improvement efforts. http://nationalqualitycenter.org/quality-improvement-resources.  Accessed 04/12, 2016.

National Breast Cancer Coalition. Quality care project LEAD®. http://www.breastcancerdeadline2020.org/get-involved/training/project-lead/QualityCareProjectLEAD.html?referrer=https://www.google.com/.  Accessed 04/16, 2016.

University of Maryland School of Pharmacy. Course detail: Healthcare quality in the US. http://www.pharmacists4knowledge.org/cips/courses/view/111.  Accessed 04/14, 2016.

National Quality Center. Training of consumers on quality (TCQ). http://nationalqualitycenter.org/nqc-activities/training-of-consumers-on-quality-tcq/.  Accessed 04/14, 2016.

New York State Department of Health AIDS Institute. NQC training of quality leaders guide: Facilitator manual to build capacity of HIV providers to lead quality management activities. . 2009.

National Quality Center. We are all partners in+care. http://www.incarecampaign.org/we-are-all-partners-in-care/.  Accessed 04/14, 2016.

National Quality Forum. Member education resource center. http://www.qualityforum.org/eduondemand/.  Accessed 04/14, 2016.

Centers for Medicare & Medicaid Services. Meaningful Measures Framework  https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/cms-quality-strategy.html. Accessed November 2017.

Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/perfmeasguide/perfmeasres.html October 2014.

“Crowdsourcing Patients’ Perspectives: A Novel Approach for Patient-Reported Outcomes.” National Quality Forum. Available at http://allh.us/9nP8

“Incorporating Patient-Reported Outcomes Into Health Care To Engage Patients And Enhance Care.” Health Affairs. April 2016. Available at http://allh.us/D3Cf

“NQF’S Health Equity Program: Improving Health and Healthcare Quality for All Through Advancements in Health Equity.” National Quality Forum. September 2017. Available at http://allh.us/QtA3

“NQF Measure Incubator.” National Quality Forum. February 2017. Available at http://allh.us/WJdM

“Shared Decision Making: A Standard of Care for All Patients.” National Quality Forum. October 2017. Available at http://allh.us/QuUx

“The Art of Authentic Person-Centered Planning.” Quality in Practice. 2009. Available at http://allh.us/dxhM

“What Matters Most: Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs.” The SCAN Foundation. September 2016. Available at http://allh.us/Xbrm

Agency for Healthcare Research and Quality, “National Quality Measures Clearinghouse, “web page, U.S. Department of Health and Human Services, undated-a. Accessed at: https://www.qualitymeasures.ahrq.gov/

“Engaging Consumers in the Quality Measurement Enterprise.” Thomas W. Concannon, Mark W. Friedberg, Ann Hwang, Kris Wiitala. RAND. 2017. Available at http://allh.us/FWfx

“Essential Attributes of a High-Quality System of Care: How Communities Approach Quality Measurement.” National Quality Forum. October 2016. Available at http://allh.us/fjur

Families USA – Measuring Health Care Quality: An Overview of Quality Measures. Accessed at: http://familiesusa.org/sites/default/files/product_documents/HSI%20Quality%20Measurement_Brief_final_web.pdf

“Caring for High-Need, High-Cost Patients – An Urgent Priority.” David Blumenthal, Bruce Chernof, Terry Fulmer, John Lumpkin, Jeffrey Selberg. The New England Journal of Medicine. September 8, 2016. Available at http://allh.us/t8XV

National Quality Center. Quality improvement resources – helpful tools to assist in your quality improvement efforts. http://nationalqualitycenter.org/quality-improvement-resources.    Accessed September 2016.

“Moving Toward Implementation of Person-Centered Care for Older Adults in Community-Based Medical and Social Service Settings: ‘You Only Get Things Done When Working in Concert with Clients.’” Journal of the American Geriatrics Society. December 2, 2015. Available at http://allh.us/umjG

“Recommendations to Improve Consumer Engagement in Quality Measurement.” Community Catalyst. Available at http://allh.us/9XHA

NQC Quality Academy: What is QI? – The NQC Quality Academy is a set of 20-minute presentations designed to give people a crash course on any given topic related to clinical quality management. http://nationalqualitycenter.org/resources/nqc-quality-academy-what-is-quality-improvement-how-can-key-principles-be-applied-in-hiv-care/

Berwick, D., and D. M. Fox, “‘Evaluating the Quality of Medical Care’: Donabedian’s Classic Article 50 Years Later,” Milbank Quarterly, Vol. 94, No. 2, 2016, pp. 237–241.

Centers for Medicare & Medicaid Services. CMS Quality Strategy 2016. Baltimore, MD: US Department of Health and Human Services; 2015. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy.pdf. Accessed December 7, 2015.

Deverka, P. A., D. C. Lavallee, P. J. Desai, et al., “Stakeholder Participation in Comparative Effectiveness Research: Defining a Framework for Effective Engagement,” Journal of Comparative Effectiveness Research, Vol. 1, No. 2, 2012, pp. 181–194.

“Join an Advisory Panel,” web page, updated June 2016. As of July 29, 2016: http://www.pcori.org/get-involved/join-advisory-panel

 

Increasing Patient-Community Capacity to Engage on Quality of Health Care Research

Glossary of Terms

This glossary provides you with important terms that are covered in this course. This glossary is not meant to be exhaustive, but rather to provide you with important terms that will supplement your learning throughout the course.

 

Introduction

  • Patient vs Person: For the purposes of this course, the term patient will be used broadly to encompass individuals, caregivers and patient advocacy organizations, etc. The NHC and its partners recognize that many in the health care community prefer “person” or “person centered care” and that “one single term cannot apply to all individuals in all situations.”

Module 1: The Changing Health Care Environment & the Role of Quality

  • National Quality Strategy (NQS) is a nationwide effort to provide direction for improving the quality of health and healthcare in the United States. It is guided by three aims: better care, healthy people and communities, and affordable care.
  • National Priorities Partnership (NPP): NPP is a partnership of 52 major national organizations with a shared vision to achieve better health, and a safe, equitable, and value-driven healthcare system. NPP was an early advocate for the creation of the National Quality Strategy (NQS) as a blueprint for achieving a high-value healthcare system. NPP continues to provide direction on healthcare policy and helps organizations pursuing the NQS to achieve quality improvement by making connections and helping to share information about innovative approaches.

Module 2: Why Quality Matters For Patients?

  • Volume to Value means measuring the outcomes that result, not just the services provided.
  • Measure: Measures are based on scientific evidence about processes, outcomes, perceptions, or systems that relate to high-quality care.
  • Performance Measure: A health care performance measure is a way to calculate whether and how often the health care system does what it should.

Module 3: Everything You Wanted to Know About Quality, But Were Too Afraid To Ask

  • Quality: How “good” something is
  • Quality of health care: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Typically expressed in a range (low to high).
  • Quality Improvement (QI) represents efforts made to make quality better, moving it from low to high.

Key Quality Stakeholders: Non-Profit Organizations

  • The National Quality Forum, or NQF, is responsible for evaluating or endorsing quality measures. It convenes a group called the Measure Applications Partnership, or MAP, a multi-stakeholder partnership that guides the U.S. Department of Health and Human Services on measures to include in federal government pay-for-performance programs.
  • The Institute for Healthcare Improvement, or IHI, is the non-profit, think-tank organization that developed the Triple Aim. IHI aims to help health care delivery systems provide value-based care that ensures the best health care.  For example, providers can use IHI tools to track quality improvement.

The remaining three organizations are accrediting bodies:

  • The National Committee for Quality Assurance, or NCQA, is an organization that accredits health plans and other types of healthcare organizations based on a set of standardized requirements.  NCQA is best known for its HEDIS measure set. HEDIS stands for Healthcare Effectiveness Data and Information Set. HEDIS is one of the most widely used sets of health care performance measure in the United States. It is used to evaluate health plans
  • The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. It originally focused on hospital accreditation only, but now accredits and certifies other types of healthcare organizations such as ambulatory care centers and nursing homes.
  • URAC, the Utilization Review Accreditation Commission, is another accreditation body similar to NCQA and the Joint Commission.  It focuses its accreditation services on disease and case management organizations, pharmacy organizations, and health plans, for example.

 Key Quality Stakeholders: Professional Societies and Membership-based organizations

  • The American Medical Association. The AMA formed an organization called the Physician Consortium for Performance Improvement. Today, PCPI is a multi-stakeholder body focused on the advancement of measurement science, quality improvement and clinical registries.
  • The Pharmacy Quality Alliance is a membership-based organization that develops and endorses quality measures for medication use, adherence, and safety.
  • The American Society of Clinical Oncology has a program called QOPI, its Quality Oncology Practice Initiative. QOPI is designed to promote excellence in cancer care by helping practices create a culture of quality improvement. QOPI provides a standard methodology and library of oncology quality measures.

Key Quality Stakeholders: The federal government – the Department of Health and Human Services, specifically – includes several departments responsible for addressing quality.

  • The Centers for Medicare & Medicaid Services – or CMS – is primarily known for its federal management of the Medicare and Medicaid programs. Over time, it has implemented many quality reporting programs that entail quality-measure reporting by Medicare and Medicaid providers, and that have most recently been associated with provider payment or reimbursement programs, for example, the Physician Quality Reporting System, and the 30-Day Hospital Readmissions Reduction Program.
  • The Agency for Healthcare Research and Quality, or AHRQ, developed the National Quality Strategy previously discussed. AHRQ is the Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care. It is known for the set of patient satisfaction surveys it developed and maintains called the Consumer Assessment of Healthcare Providers and Systems – or CAHPS measures
  • “Healthy Communities, Healthy People” is the vision for The Health Resources and Services Administration, or HRSA. The mission of HRSA is to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs.  HRSA offers a clinical quality and performance measures toolkit.
  • The Substance Abuse and Mental Health Services Administration is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.
  • The Administration for Community Living, or ACL, includes several Health and Human Services agencies including (but not limited to): The Administration on Aging; Administration on Disabilities; and National Institute on Disability, Independent Living, and Rehabilitation Research. One goal of this group is enabling people with disabilities and older adults to live in the community through the availability of and access to high-quality, long-term services and supports, including supports for families and caregivers.
  • Insurers and managed care organizations use the measures developed NCQA’s HEDIS measures, for example – to understand how providers are performing. The also develop measures that they use internally and may not share publicly because they view them as proprietary to their business. This information is then used to negotiate contracts with providers and set reimbursement or payment fees.
  • The LeapFrog Group is a non-profit organization founded by employers and other purchasers of healthcare. This group is perhaps best known for its Leapfrog Hospital Survey, which collects and reports on hospital performance – to inform the public about the quality of hospital care.
  • Bridges to Excellence is a family provider recognition programs managed by the Health Care Incentive Improvement Institute (HCI3), a non-profit organization dedicating to improving health systems. With Bridges to Excellence, providers are recognized and rewarded based on the quality of care they deliver. This recognition is often advertised in provider marketing materials and it also influences how much they are paid for care delivery.

Module 4: Where Do Quality Measures Come From?             

  • Structure measures assess health care infrastructure. They can assess provider or organization capacity, as well as determining if the technologies and infrastructure are in place to deliver adequate healthcare services.  This could be the number of surgeons on staff or the number of available surgical units.
  • Process measures assess steps that should be followed to provide good care.
  • Outcome measures assess the results of health care that are experience by patients. They reflect the desired or undesired results due to having the health care processes and structure in place.
  • Patient-Reported Outcome Measures (PROMs) is an adequate, validated or tested, tool to collect information reported by patients.

NCQA Measure Development Process

  • Step 1: Identification and selection of the measure to pursue. The measure developer identifies the clinical area to evaluate through information gathering. — Patients can research and recommend an area for measure development.
  • Step 2: Measure Development, which involves developing the measure with the appropriate advisory panels and field testing the measure to determine its feasibility, reliability and validity. — Patients can participate on expert advisory panels.
  • Step 3: Field testing and evaluation. The measure is vetted or reviewed with various stakeholders through public comment before making a final recommendation. – Patients can comment, usually through an on-line system or letter, on the measure and its specification.
  • Step 4: Implementation, which involves data collection for first-year measures. Any new measures or changes to existing measures are available for public comment.
  • Step 5: Measure evaluation is next. For an NCQA measure,” organizations will collect, be audited on and report on first year measures, but results” [are not] publicly reported for individual organizations in the first year. This allows implementation problems to be ironed out before results are available” on a public website.
  • Step 6: Continuous improvement. NCQA continuously monitor and evaluate the performance of measures to determine if measure specification updates are needed based. If a measure no longer improves health care or is consistent with clinical guidelines, it may be retired.

Module 5: The Role of Quality in Value-Based Payment

  • The CMS Star Ratings program includes several quality measures that are categorized into five categories:
    • Staying healthy: This category includes measures that evaluate whether members got various screening tests, vaccines, and other routine check-ups to help them stay healthy.
    • Managing chronic (long-term) conditions: Medicare Advantage plans are measured on how often members with certain conditions get recommended tests and treatments to help manage their condition.
    • Individual Experience: Individual member experience with the health plan and their doctors.
    • Complaints: Member complaints and changes in the health plan’s performance make up category 4.  Here CMS evaluates the frequency of complaints from the member with the Medicare Advantage plan, and whether the complaint was resolved in a timely manner.
    • Health Plan Customer Service: Medicare Advantage plans are measured on health plan customer service, including, for example, how well the plan handles member appeals.
  • Medicare and CHIP Reauthorization Act (MACRA): In 2015, MACRA was signed into law. It addresses several components of the health care system:
    • It ended the Sustainable Growth Rate or SGR payment formula for providers, which had been in place since 1997.  The SGR formula-based payments to Medicare physicians solely based on the volume of services they provide.
    • MACRA extended the Children’s Health Insurance Program – or CHIP, as some refer to it.
    • It mandates that pay-for-performance-type models will replace the fee-for-service payment models that have been in place for decades.
  • Quality Payment Program (QPP): Based on the MACRA provisions, CMS developed the Quality Payment Program, called the QPP, which sets Medicare-specific requirements associated with pay-for-performance and value-based care. There are two paths in the QPP that Medicare providers can choose from:
    • The first is the Advanced Alternative Payment Models or Advanced APM. Clinicians who decide to participate in an Advanced APM can earn an incentive payment for participating in an innovative payment model that focuses on patient-centered care.  All providers are incentivized to provide highly coordinated care.
    • The other track is the Merit-Based Incentive Payment System, or MIPS. With this track, clinicians are required to submit quality measure data, and based on their performance over time, they will receive a payment adjustment. These doctors would get a bonus for better quality performance.
  • Center for Medicaid and CHIP Services:  There are also quality measurement and improvement initiatives in the Medicaid program, driven by the Center for Medicaid and CHIP Services – or CMCS – in partnership with states and advocacy organizations.  CMCS is responsible for partnering with states to share best practices and provide technical assistance to improve the quality of care.
    • There are two initiatives that measure and drive Medicaid provider performance. The first is the Home and Community-Based Services Consumer Assessment of Healthcare Providers and Systems survey, or HCBS CAHPS. This is a survey that assesses the Medicaid beneficiary’s experience with long-term care and disability support services.
    • The second includes a set of Medicaid Quality Improvement Initiatives for children such as screening, oral health, and vaccines. There are also adult initiatives focused on tobacco cessation and prevention initiatives including reducing obesity and increasing vaccination rates.

Module 6: Turning What We’ve Learned into Practice

Engagement Actions: Personal

  • Complete a questionnaire for an office visit, hospitalization, or other interaction with the health care system,
  • Be aware of the quality of care for you or that of your family members.  You can choose doctors and hospitals on how they rate on quality.
  • Continue to educate yourself and your peers on quality measurement and quality improvement.
  • These are all individual or personal actions you can take that don’t require a lot of time or resources.

Engagement Actions: Participation

  • Volunteer to serve on local health care committees focused on quality, such as a local hospital patient and family engagement committee.
  • Serve on a national organization committee or technical expert panel as the patient voice with organizations such as the National Quality Forum and the Centers for Medicare and Medicaid Services.
  • Serve on consumer advisory councils or boards of directors. You can recruit others to become involved in ensuring that quality measurement stakeholders hear and include the patient voice.
  • Educate others on quality to help build engagement capacity.

These actions may take a little more effort than what is required for the personal actions, but they may have a big impact on the quality of health care in your community.

Engagement Actions: Coordination

  • You can collect patient stories or deploy a survey to your constituents and learn what is important to your organization on quality of care.
  • Perform research to develop a measure for your disease, condition, or population.
  • Collaborate with other organizations like yours by encouraging your organization to join groups like the National Quality Forum or by networking with other patient advocacy organizations to provide a stronger voice to quality stakeholder organizations.

The action requires more time and resource commitment that individual and participation actions.

Engagement Actions: Leadership

  • Help generate standards of care;
  • You can call for or generate information that could impact quality for your disease, condition, or population;
  • Organizations can prepare position papers or policy briefs that will further highlight the need for quality measures in your area of focus; or you can
  • Advocate for legislation that improves quality measurement and related programs.

These are the kind of actions that will require people and resources to achieve the organization’s goals in quality.

Additional Resources