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QUALITY AND STARS

Preparing for a “Universal Foundation” of quality measures

Change is on the horizon for health plan quality measurement and reporting as the Centers for Medicare & Medicaid Services (CMS) looks to standardize measures across numerous programs. In summer 2022, the agency first proposed the use of consistent, nationally standardized quality core measures in Medicaid and the Children’s Health Insurance Program (CHIP).

The Core Sets are designed to measure the quality of care for beneficiaries on a national scale, monitor performance at the state level, and improve the overall quality of healthcare. They include a range of measures to evaluate how Medicaid and CHIP coverage is meeting the needs of individuals and their communities, determine whether there are health disparities, and identify how the quality of care can be improved.

“The Medicaid and CHIP Core Sets of quality measures for children, adults, and health home services are key to promoting health equity. They will allow us not only to identify health disparities but also to implement interventions based on the very data that make those disparities clear.” — Chiquita Brooks-LaSure, CMS Administrator

CMS is currently asking for voluntary reporting for the new measures, but reporting becomes mandatory in 2024. Its aim is to reduce provider and plan burden by streamlining processes, aligning resources, allowing providers to focus their attention on standards that are meaningful across populations, advancing equity, and aiding in reporting.

Universal Foundation quality measures

In addition to the 2022 standardization measures, CMS asked for comments on its “Universal Foundation” quality measures in the 2024 Medicare Advantage and Part D Advance Notice. This would create a standard baseline across all CMS quality programs for adult and pediatric populations and ease the burden of having a multitude of different reporting requirements.

CMS says the Universal Foundation quality measures are crucial to promoting health equity. The measures selected are meant to address many of the health problems associated with things such as morbidity and mortality for both children (Figure 1) and adults (Figure 2) in the United States. The measures selected will help CMS recognize, track, and address disparities among and within populations.

Domain

Measure

Wellness and prevention        

  • Well-child visits (well-child visits in the first 30 months of life; child and adolescent well-care visits)
  • Immunization (childhood immunization status; immunizations for adolescents)
  • Weight assessment and counseling for nutrition and physical activity for children and adolescents
  • Oral evaluation, dental services

Chronic conditions

  • Asthma medication ratio (reflects appropriate medication management of asthma)

Behavioral health

  • Screening for depression and follow-up plan
  • Follow-up after hospitalization for mental illness
  • Follow-up after emergency department visit for substance use
  • Use of first-line psychosocial care for children and adolescents on antipsychotics
  • Follow-up care for children prescribed attention deficit–hyperactivity disorder medication

Person-centered care

  • CAHPS overall rating measures

Figure 1. Preliminary Pediatric Universal Foundation measures.

Domain

Measure

Wellness and prevention        

  • Colorectal cancer screening
  • Breast cancer screening
  • Adult immunization status

Chronic conditions

  • Controlling high blood pressure
  • Hemoglobin A1c poor control (>9%)

Behavioral health

  • Screening for depression and follow-up plan
  • Initiation and engagement of substance use disorder treatment

Seamless care coordination

  • Plan all-cause readmissions or all-cause hospital readmissions

Person-centered care

  • CAHPS overall rating measures

Equity

  • Screening for social drivers of health

Figure 2. Preliminary Adult Universal Foundation measures.

The Universal Foundation is intended to focus providers’ attention on measures that are meaningful for the health of broad segments of the population. On the administrative side, CMS says the Universal Foundation will aid the transition from manual reporting of quality measures to seamless, automatic digital reporting, and permit comparisons among various quality and value-based care programs to help the agency better understand what drives quality improvement and what does not.

These proposals aim to reduce provider and plan burden by streamlining processes, aligning resources, allowing providers to focus their attention on standards that are meaningful across populations, advancing equity, and aiding in reporting. The measures selected are also meant to outline many of the health problems associated with conditions such as depression, substance abuse disorders, morbidity, and mortality in the United States. Standardization may help to ultimately illustrate what drives the improvement of quality care—but comes with several potential implementation challenges. These include:

  • Health plans have already created their own quality measures and might not want to use another set of newly created measures
  • Providers are burned out and may not be interested in new initiatives
  • Measures can become misaligned from their original intent or the intent of a program that adopted it
  • There is still a lack of clarity around how, when, and where this Universal Foundation will be used

However, there are steps health plans can take now to prepare their program for success when the CMS Core Measures and the Universal Foundation are implemented. These include:

  • Leveraging your EMR data and using it for care coordination
  • Using your HEDIS® and other population health data to understand the risk profile of your member population
  • Working directly with your members to help them understand their own medical data so that they are familiar with their plan of care and physician's expectations

The ultimate goal is for health plans to work toward alignment between their own organizations, providers, and members. Don’t wait for CMS to confirm these changes and start getting ready to measure them now, as reporting could become mandatory as soon as 2024. Think of these efforts as setting a baseline for collecting, tracking, and benchmarking data so your organization is fully prepared once reporting becomes mandatory.

CMS's proposal to use consistent, nationally standardized quality measures in Medicaid, CHIP, Medicare Advantage, and Part D Advance Notice could ultimately lead to improved health outcomes and advance health equity. However, it is crucial to prepare for standardization across multiple programs and stakeholders by adopting best practices, identifying and overcoming barriers to adoption, and regularly monitoring progress.

In addition to HEDIS® and Star Ratings, Cotiviti’s Quality and Stars solutions support more than 30 quality measurement programs across Medicaid, commercial exchange, and custom measures. Learn how our Quality Intelligence solution enables payers to:

  • Drill down to member-level claim detail for optimal insight and analysis
  • Customize views to display the most meaningful data and facilitate smooth workflows
  • Get visibility and insight at every level to find your best improvement opportunities through our transparent data model

Read the fact sheet

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

WRITTEN BY

Branka Sustic
Overseeing Cotiviti’s Risk Adjustment and Quality and Stars solutions, Branka provides leadership in product and business development, client program management, and strategy to assist health plans in meeting their quality goals, optimization of revenue, and risk mitigation. A leader with more than 20 years of healthcare experience, she is known for creating and establishing operational and support plans leading to increased client satisfaction and performance.

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