Core Measure Sets: Will you measure up?

One key challenge in the transition from volume-based to value-based reimbursement is the development and adoption of uniform and reliable clinical quality and efficiency measures across payers.

Presently, different payers utilize different measure requirements, resulting in confusion and complexity for reporting providers.

A recent study reported that physician practices in four common specialties annually spend an average of 785 hours per physician dealing with the reporting of quality measures.

The Core Quality Measures Collaborative

To address the need for standardization, America’s Health Insurance Plans (AHIP) in 2014 convened leaders from the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF), as well as national physician organizations, to form the Core Quality Measures Collaborative. First, the Collaborative established the “3Rs” as guiding principles in developing core measure sets:

  • Reduce the total number of measures by eliminating low-value measures
  • Refine the remaining measures to further ease the burden of data collection and reporting
  • Relate measures to patient health outcomes, focusing on “measures that matter”

Also, recognizing that quality measurement now tends to focus on primary care, the Collaborative made a commitment to develop specialty-specific core measure sets.

To begin their work, Collaborative members organized into workgroups for each of the identified core measure sets. Each workgroup reviewed measures currently used by CMS and health plans, as well as NQF-endorsed measures. Based on their review and discussion, the workgroups identified consensus core measure sets for the selected clinical areas. These measure sets were then reviewed by all Collaborative members before being finalized.

 On February 16, 2016, the Collaborative released to the public its first seven core measure sets for physician quality programs for the following clinical areas: 

  • Accountable Care Organizations, Patient Centered Medical Homes and Primary Care
  • Cardiology
  • Gastroenterology
  • HIV and Hepatitis C
  • Obstetrics and Gynecology
  • Medical Oncology

Medical Oncology Core Measure Set

For medical oncology, there are specific measures for three cancers:

Breast Cancer

  1. Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under 70 with AJCC T1c, or Stage II or III hormone receptor negative breast cancer
  2. Patients with breast cancer and negative or undocumented human epidermal growth factor receptor 2 (HER2) status who are spared treatment with trastuzumab
  3. Trastuzumab administered to patients with AJCC stage I (T1c) – III and human epidermal growth factor receptor 2 (HER2) positive breast cancer who receive adjuvant chemotherapy

Colorectal Cancer

  1. Adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis to patients under the age of 80 with AJCC III (lymph node positive) colon cancer
  2. KRAS gene mutation testing performed for patients with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy
  3. Patients with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-epidermal growth factor receptor monoclonal antibodies

Prostate Cancer

  1. Avoidance of overuse of bone scan for staging low risk prostate cancer patients
  2. Radical prostatectomy pathology reporting

The following measures relating to hospice and end-of-life care also are included in the medical oncology core measure set:

  1. Proportion receiving chemotherapy in the last 14 days of life
  2. Proportion with more than one emergency room visit in the last 30 days of life
  3. Proportion admitted to the ICU in the last 30 days of life
  4. Proportion not admitted to hospice
  5. Proportion admitted to hospice for less than three days
  6. Pain intensity quantified

Additionally, the document lists several areas for future measure development, including pain control, functional status/quality of life, shared decision-making, appropriate use of chemotherapy, care management, and cost of care. The Collaborative emphasized the need to move from “check-box” process measures to outcomes measures. At the same time, the Collaborative acknowledged the rapid pace at which oncology treatments and protocols for treatment are changing makes it more challenging to identify reliable measures for this specialty.

What’s Next and What You Can Do

The Collaborative’s payer participants have committed to incorporating these measures into their plans as soon as feasible. CMS has indicated it will utilize measures from each of the core sets in the new Medicare Merit-Based Incentive Payment System (MIPS). The agency also is working with federal partners including the Office of Personnel Management, Department of Defense, and Department of Veterans Affairs, as well as state Medicaid plans to align quality measures where appropriate.

In addition to developing additional core measure sets, the Collaborative will monitor the use of these initial measure sets, making modifications as needed and based on lessons learned, including minimizing unintended consequences and updating the sets as better measures become available.

For oncologists, the good news and the bad news are the same:  payers will utilize physicians’ scores on these measures to adjust fee-for-service reimbursement. This is good news, to the extent an oncologist now is collecting data and reporting on multiple measures for different payers. And it is bad news, to the extent more payers transition to value-based reimbursement, given the availability of consensus performance measures. 

Oncology practices, therefore, should review the consensus core measure set carefully and evaluate and address their capability and capacity to collect data and report on each measure.  Ideally, a practice would determine a historical baseline score for each oncologist on each relevant measure, thus identifying opportunities for improvement. 

Armed with this information, a practice then should review treatment protocols to determine what changes should be implemented to improve scores on each measure. Doing this work now, before payers implement programs based on the core measure set, will help protect the practice’s financial health in the long run.