Measuring Quality in Value-Based Care: A More Targeted Approach
October 18, 2023

This blog post is part of our Policy Pulse series, which spotlights crucial policy issues in independent and community-based primary care, along with potential solutions from Aledade’s Policy team.

Quality reporting is critical to accountable care and value-based care. The foundation of advanced alternative payment models and accountable care organizations (ACOs) is built on paying clinicians for providing high-quality care rather than the quantity of services they deliver. 

To accomplish this, quality needs to be measured using standardized methods of data collection and reporting. Aledade works with physician-led ACOs in the Medicare Shared Savings Program (MSSP), Medicare Advantage, Medicaid and commercial contracts. From this vantage point, we know that there are many overused quality measures, often with cumbersome documentation requirements, that do not improve patient health outcomes. We see firsthand health plans that have overly long lists of measures in their contracts and how burdensome it can be for the primary care team.

CMS recently launched its Universal Foundation concept, which is a commitment to aligning a core set of measures across all of the agency’s programs. We share the goal of ensuring stakeholders are measuring quality across the care continuum in a way that promotes the best, safest and most equitable outcomes for all; however, to really improve patient care, a more targeted measure set is needed. 

In our experience, lists with more than 10 measures often result in clinicians’ attention being diverted away from patient-centered, outcomes-based care due to time-consuming administrative tasks and data submission efforts. For example, MSSP has the best set of impactful measures on the clinical side with its focus on blood pressure control, A1c levels for individuals with diabetes, and depression screening and follow-up. 

In our experience, lists with more than 10 measures often result in clinicians’ attention being diverted away from patient-centered, outcomes-based care due to time-consuming administrative tasks and data submission efforts.

We advocate to eliminate the medication adherence measure in Stars. 

While we agree with the Universal Foundation concept to align quality measures across programs, we believe it does not go far enough to reduce measures that are burdensome and duplicative. Medication adherence in Star ratings is one measure that fits that description. The intent behind the medication adherence measure is to improve specific medical conditions (i.e., diabetes, hypertension, high cholesterol) by incentivizing care teams to ensure patients can get and take their prescribed medications. 

This is a triple-weighted measure, which means how clinicians do counts more – and clinicians are incentivized to spend more time and effort to hit these targets. But the measure is not very precise. For example, patients might be taking prescribed medications but might not need to be on them anymore. Or the pharmacy may be processing a discount card or program that interferes with prescription documentation. Most importantly, outcomes measures for conditions treated by these medications are a far better measure of quality of care and improved health than medication adherence. 

Medicare Clinical Quality Measures should remain a permanent option. 

In the 2024 Proposed Physician Fee Schedule, CMS has proposed to introduce the Medicare Clinical Quality Measures (CQM) option to ease the transition to digital quality measure reporting. CMS requires that clinicians report electronic Clinical Quality Measures (eCQMs), which use data from electronic health records and/or health information technology systems to measure health care quality. 

CMS has set a goal to move ACOs participating in MSSP away from reporting quality measures via web interface to reporting electronically. CMS’s requirements will burden primary care teams’ processes for reporting quality and performance measures. Aledade and the ACO community have been emphasizing the unintended consequences and data challenges ACOs face in implementing these requirements, including added costs from having to aggregate data across all practices in different EHRs. We are pleased that CMS is recognizing these burdens and proposing to provide a transition in the form of Medicare CQMs, but some of the challenges voiced by Aledade and the ACO community remain. The CQM option is time limited, and CMS is maintaining the eCQM reporting option in the long term.

CMS should view the Medicare CQM option as a permanent reporting option until digital quality measurement and reporting is feasible for all ACOs. Quality measurement in MSSP should remain aligned with the finances of the ACO model and focus on patients who have primary care relationships with the ACO. And, ultimately, quality measurement in MSSP should facilitate comparisons with other major programs like Medicare Advantage that measure the participants in the specific program, not all patients.