Introduction

The United States government is the largest provider of healthcare and health-related services to the American people. HHS administers healthcare programs that directly affect over 175 million Americans through Medicaid, Medicare, the Children's Health Insurance Program (CHIP), and the Health Insurance Exchanges administered by the Centers for Medicare & Medicaid Services (CMS); the Indian Health Service (IHS) serving American Indians and Alaska Natives; and health services to people who are geographically isolated and/or economically or medically vulnerable, through the Health Resources and Services Administration (HRSA).1 Similarly, the DoD provides medical benefits to 9.5 million active duty personnel, military retirees, and their families through the Military Health System, and the VA serves over 9 million veterans enrolled in the VA healthcare program.2 The Federal Employees Health Benefits Program, administered through the Office of Personnel Management (OPM), provides healthcare benefits for approximately 8.2 million federal civilian employees, retirees, and their families.3 Total expenditures for the U.S. healthcare system are projected to be over $3.8 trillion in 2019.4 Given the large number of Americans served and the cost of these programs the federal government has a clear responsibility in assessing and promoting the quality5 of the healthcare it oversees.

Over the past two decades, quality measurement programs have expanded dramatically, with thousands of measures now used in a variety of public and private programs for accountability, value-based payment, public reporting, and quality improvement across care settings and provider types. While there have been notable successes, meaning improved health outcomes, driven by the increased focus on quality measurement and improvement, healthcare providers and organizations, as well as patients, have experienced significant burdens as a result of proliferating measurement requirements. Providers are required to report duplicative, overlapping, or conflicting measures to multiple stakeholders, such as federal and state governments, private payers, and accreditation bodies.

Because the current measurement landscape is an outgrowth of multiple legislative and regulatory acts, the current state reflects a variety of uncoordinated initiatives, with little alignment across settings or payers or around common goals. The current QME lacks a coordinated governance structure for assessing the benefit of these measurement initiatives against their imposed cost. Further, the information gleaned from the QME is often not shared with providers or the public in a manner that is timely or meaningful enough to inform quality improvement efforts and decision-making. Over the past several years, key medical, consumer, and business stakeholders and government leaders have voiced the need to evaluate and improve the existing QME.6 HHS, DoD, and VA have made concerted efforts in recent years to improve federal health quality programs in response to these concerns. This Health Quality Roadmap builds on those efforts and provides a unified approach to aligning quality measurement across federal programs that support and enhance patient health outcomes.

Principles for Reform

The policies outlined in this Roadmap support the Administration's goals of improving transparency, reducing provider burden, allowing informed consumer and purchaser decision-making, and ultimately improving health outcomes. The federal government intends to provide leadership to accelerate improvement across the QME, with the understanding that direct stakeholder engagement and equal partnership with the private sector will be necessary to drive meaningful change nationally.

The following principles—identified collaboratively with input from a wide array of government, academic, and industry stakeholders—will underpin the solutions identified in this Roadmap:

Quality Information is Available and Meaningful. The QME should produce accurate, timely, and actionable information with sufficient clinical detail on healthcare quality for:

• patients selecting providers and making choices about their healthcare
• providers identifying opportunities for improvement in providing care
• payers and policymakers seeking to align financial incentives with health quality goals

Balance Administrative Burden with the Goal of Obtaining Meaningful Information. Collecting and reporting data for quality metrics requires time and resources. The need for such data should be evaluated in light of the administrative burden incurred in collecting it and the benefits derived from reporting it. For example, data collected to support the QME should be drawn to the extent feasible from information produced as part of typical clinical workflows and should be collected electronically. Measures that are reported should result in improved patient outcomes.

Alignment of Measurement Priorities. HHS, in collaboration with DoD, VA, and the private sector, should align measurement priorities and create a parsimonious set of metrics targeting concrete, realistically achievable healthcare quality goals. For the purposes of this Roadmap, a parsimonious measure set is one that employs the least number of measures necessary to provide sufficient information to the intended audience. This effort will focus on alignment within and across federal programs, recognizing that the direction set by the federal government may shape the direction of the national QME more broadly, including the QME used by private sector actors. Given the impact of federal programs on the broader national QME, state and private sector actors will be engaged as equal partners in informing federal alignment efforts, while retaining their full autonomy to manage their own quality programs.

Cohesive Measurement Stewardship. A transparent multi-stakeholder mechanism should govern the measure development and stewardship process. This process should ensure transparent contracting for measure development, using input from multiple stakeholders (patients, providers, and payers); should ensure measures are scientifically and statistically sound; should include a mechanism for pilot-testing measures prior to broad use in quality programs; and should include ongoing impact assessment and cost-benefit analysis to regularly validate each measure's continued use. This process should consider both clinical and patient-reported outcome measures.

Reward Innovation and Improvement. Measures—particularly those tied to incentives—should motivate quality improvement (or reduce costs while maintaining quality), should be tied to concrete behaviors that providers can change, should support innovators, should be based on meaningful differences in performance, should be constructed to minimize gaming, and should avoid unintended consequences.

Leverage What Works and Reform the Rest. Whereas wide-scale reform is needed to actualize an enhanced QME, well-established healthcare quality frameworks and effective initiatives with proven results should be leveraged to ensure a robust and evidence-based process. Similarly, initiatives that have not demonstrated meaningful improvement in the QME should be reformed or retired.

• 1. This number reflects 145 million Americans served by CMS programs (https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/FY2020-CJ-Final.pdf), 30 million by HRSA (https://data.hrsa.gov/data/fact-sheets), and 2.5 million by IHS (https://www.ihs.gov/newsroom/factsheets/ihsprofile/).
• 2. https://health.mil/I-Am-A/Media/Media-Center/Patient-Population-Statistics/Patients-by-Beneficiary-Category and https://www.va.gov/health/.
• 3. https://www.opm.gov/healthcare-insurance/healthcare/reference-materials/2019-open-season.pdf.
• 4. Sisko AM et al. National Health Expenditure Projections, 2018–27: Economic And Demographic Trends Drive Spending And Enrollment Growth. Health Affairs 2019 38:3, 491-501
• 5. For purposes of this Roadmap, quality includes the domains of safety, timeliness, efficiency, effectiveness, equitability, and patient-centeredness.
• 6. For example, U.S Government Accountability Office. Health Care Quality: HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures. GAO-17-5: October 2016; U.S. GAO. Health Care Quality: CMS Could More Effectively Ensure Its Quality Measurement Activities Promote Its Objectives GAO-19-628: Sep 19, 2019.