CMS and AHIP agree on new quality measures for physicians - ‘HOW DO WE IMPLEMENT?’

The Core Quality Measures Collaborative made up of the Centers for Medicare & Medicaid Services (CMS) and major commercial health plans, in conjunction with medical associations and employer and consumer groups, released on Tuesday, February 16 the first set of "core measures" that the government and private payers plan to use for value-based payments. Participating health insurers include members of America's Health Insurance Plans (AHIP), as well as Aetna and UnitedHealth Group.

Following 18 months of consensus work, the group produced seven sets of clinical quality measures, a total of 37 measures, believed to support multi-payer alignment for physician, group practice and health system quality program in the following seven sets:

  • Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), and Primary Care
  • Cardiology
  • Gastroenterology
  • HIV and Hepatitis C
  • Medical Oncology
  • Obstetrics and Gynecology
  • Orthopedics

The majority of the 37 quality measures are consistent with or drawn from NCQA, HEDIS and PCMH measures already in use, including readmission rates, diabetic measures, etc.

The goal of this work was to focus on broadly agreed upon quality improvement actions, simplify quality reporting for healthcare providers, make actionable information available to consumers to inform care choices and most importantly, to create a consistent platform to support the necessary shift from fee-for-service to value-based payments and alternative payment models. Achieving consensus is a tremendous step in the right direction for meaningful healthcare transformation.

ACOs under the Medicare Shared Savings Programs have been accountable to report against a similar set of quality measures. These new proposed measures would replace the measures for the current period, which started in 2015. Quality measure reporting requirements have only applied to Medicare ACO-engaged providers, and ACO organizations have invested significant time and resources to meet the reporting requirements. Absent the ACO requirements and incentives, the transition will be slow and challenging for smaller, independent physician groups.

Today, commercial payers independently contract with physicians and health systems, absent any standards, and have established custom and varied quality measure sets that have created a significant burden for management, measurement, and reporting. The application of the newly defined core measure set by commercial payers will be voluntary, using these measures as the quality gate in alternative payment models or ACO-like risk contracting. This cannot happen overnight. Commercial payers will have to phase in these measures as providers contract renewals and new program negotiations roll out.

Whether payers choose to adopt a set standard or a custom measure set, in the end, the goal is the same – to help engage individuals and close gaps in care in order to improve measurements and results. Eliza Corporation has been working with the HEDIS, STARS and NCQA quality standards for over 15 years and realized positive member outcomes, raised HEDIS scores and STAR ratings, enhanced medication adherence and refill rates, and increased member retention. The fist step is using behavior-driven healthcare analytics to identify actionable data and then applying a multi-channel communications plan that make interventions more efficient and effective. Healthcare i complicated, but Eliza is here to help. For more information on Eliza’s provider and payer solutions, contact us at or 844.343.1441.



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