[Federal Register Volume 79, Number 136 (Wednesday, July 16, 2014)]
[Notices]
[Pages 41563-41579]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-16391]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES


Secretarial Review and Publication of the Annual Report to 
Congress and the Secretary Submitted by the Contracted Consensus-Based 
Entity Regarding Performance Measurement

AGENCY: Office of the Secretary of Health and Human Services, HHS.

ACTION: Notice.

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SUMMARY: This notice acknowledges the Secretary of the Department of 
Health and Human Services' (HHS) receipt and review of the 2014 Annual 
Report to Congress and the Secretary submitted by the contracted 
consensus-based entity (CBE) as mandated by section 1890(b)(5) of the 
Social Security Act, as created by section 183 of the Medicare 
Improvements for Patients and Providers Act of 2008 (MIPPA) and

[[Page 41564]]

amended by section 3014 of the Affordable Care Act of 2010. The statute 
requires the Secretary to review and publish the report in the Federal 
Register together with any comments of the Secretary on the report not 
later than six months after receiving the report. This notice fulfills 
those requirements.

FOR FURTHER INFORMATION CONTACT: Corette Byrd, (410) 786-1158.
    The order in which information is presented in this notice is as 
follows:

I. Background
II. NQF Report of 2013 Activities to Congress and the Secretary of 
the Department of Health and Human Services
III. Secretarial Comments on the 2014 Annual Report to Congress and 
the Secretary
IV. Future Steps
V. Collection of Information Requirements

I. Background

    Rising health care costs coupled with the growing concern over the 
level of and variation in quality and efficiency in the provision of 
health care raise important challenges for the United States. Section 
183 of MIPPA created Section 1890 of the Social Security Act, which 
requires the Secretary of the Department of Health and Human Services 
(HHS) to contract with a consensus-based entity (CBE) to perform 
multiple duties pertaining to health care performance measurement. 
These activities support HHS's efforts to promote high-quality, 
patient-centered, and financially sustainable health care. The statute 
mandates that the contract be competitively awarded for a period of 
four years and allows it to be renewed under a subsequent bidding 
process.
    In January, 2009, a competitive contract was awarded by HHS to the 
National Quality Forum (NQF) for a four-year period. The contract 
specified that the CBE should conduct its business in an open and 
transparent manner, provide the opportunity for public comment and 
ensure that membership fees do not pose a barrier to participation in 
the scope of HHS's contract activities, if applicable.
    The Affordable Care Act of 2010 amended the statutory requirement 
for the CBE by adding new requirements for annual reporting to Congress 
and the Secretary of HHS and for convening multi-stakeholder groups and 
by providing additional funding for the work of the CBE.
    Anticipating the end of the first contract, HHS solicited proposals 
for continued CBE work. After an open competition, a second four-year 
contract was awarded to NQF in 2012. Although the two contracts were in 
effect simultaneously for a short period of time, work of the two 
contracts did not overlap. Once the initial contract ended, task orders 
for work were awarded under the second contract. This annual report 
includes work conducted in calendar year 2013 under both the original 
contract which ended in 2013 and the subsequent contract.
    The two HHS contracts in effect during 2013 include the following 
major tasks:
    Priority Setting Process: Formulation of a National Strategy and 
Priorities for Health Care Performance--The CBE shall synthesize 
evidence and convene key stakeholders to make recommendations on an 
integrated national strategy and priorities for health care performance 
measurement in all applicable settings. The CBE shall give priority to 
measures that: address the health care provided to patients with 
prevalent, high-cost chronic diseases; provide the greatest potential 
for improving quality, efficiency and patient-centered health care; and 
may be implemented rapidly due to existing evidence, standards of care 
or other reasons. Additionally, the CBE shall take into account 
measures that: May assist consumers and patients in making informed 
health care decisions; address health disparities across groups and 
areas; and address the continuum of care across multiple providers, 
practitioners and settings.
    Endorsement of Measures: Implementation of a Consensus Process for 
Endorsement of Health Care Quality Measures--The CBE shall provide for 
the endorsement of standardized health care performance measures. This 
process shall consider whether measures are evidence-based, reliable, 
valid, verifiable, relevant to enhanced health outcomes, actionable at 
the caregiver level, feasible to collect and report, and responsive to 
variations in patient characteristics such as health status, language 
capabilities, race or ethnicity, and income level and is consistent 
across types of health care providers including hospitals and 
physicians.
    Maintenance of Consensus Endorsed Measures--The CBE shall establish 
and implement a process to ensure that endorsed measures are updated 
(or retired if obsolete) as new evidence is developed.
    Convening Multi-Stakeholder Groups--The CBE shall convene multi-
stakeholder groups to provide input on: (1) The selection of certain 
categories of quality and efficiency measures, from among such measures 
that have been endorsed by the entity; and such measures that have not 
been considered for endorsement by such entity but are used or proposed 
to be used by the Secretary for the collection or reporting of quality 
and efficiency measures; and (2) national priorities in the delivery of 
health care services for consideration under the national strategy. The 
CBE provides input on measures for use in certain specific Medicare 
programs, for use in programs that report performance information to 
the public, and for use in health care programs that are not included 
under the Social Security Act. The multi-stakeholder groups consider 
measures to be implemented through the federal rulemaking process for 
various federal health care quality reporting and quality improvement 
programs including those that address certain Medicare services 
provided through hospices, hospital inpatient and outpatient 
facilities, physician offices, cancer hospitals, end stage renal 
disease (ESRD) facilities, inpatient rehabilitation facilities, long-
term care hospitals, psychiatric hospitals, and home health care 
programs.
    Annual Report to Congress and the Secretary--Under section 
1890(b)(5)(A) of the Act, by not later than March 1 of each year 
(beginning with 2009) the CBE shall submit to Congress and the 
Secretary of HHS an annual report. The report shall contain a 
description of:
    (i) The implementation of quality and efficiency measurement 
initiatives and the coordination of such initiatives with quality and 
efficiency initiatives implemented by other payers;
    (ii) recommendations on an integrated national strategy and 
priorities for health care performance measurement;
    (iii) performance of its duties required under its contract with 
HHS;
    (iv) gaps in endorsed quality and efficiency measures, which shall 
include measures that are within priority areas identified by the 
Secretary under the National Quality Strategy established under section 
399HH of the Public Health Service Act (National Quality Strategy), and 
where quality and efficiency measures are unavailable or inadequate to 
identify or address such gaps;
    (v) areas in which evidence is insufficient to support endorsement 
of quality and efficiency measures in priority areas identified by the 
Secretary under the National Quality Strategy, and where targeted 
research may address such gaps; and
    (vi) the convening of multi-stakeholder groups to provide input on: 
(1) The selection of quality and efficiency measures from among such 
measures that have been endorsed by the CBE and such measures that have 
not been considered for endorsement by the CBE but are used or proposed 
to be used by the Secretary for the collection

[[Page 41565]]

or reporting of quality and efficiency measures; and (2) national 
priorities for improvement in population health and the delivery of 
health care services for consideration under the National Quality 
Strategy.
    Section 1890(b)(5)(B) of the Social Security Act requires 
Secretarial review and publication of this report in the Federal 
Register, together with any comments of the Secretary on the report not 
later than 6 months after receiving the report. We have included our 
comments in section IV below.
    The first annual report covered the performance period of January 
14, 2009 to February 28, 2009 or the first six weeks post contract 
award. In March 2009, NQF submitted the first annual report to Congress 
and the Secretary of HHS. Given the short timeframe between award and 
the statutory requirement for the submission of the first annual 
report, this first report provided a brief summary of future plans. The 
Secretary published a notice in the Federal Register in compliance with 
the statutory mandate for review and publication of the annual report 
on September 10, 2009 (74 FR 46594).
    In March 2010, NQF submitted to Congress and the Secretary the 
second annual report covering the period of performance of March 1, 
2009 through February 28, 2010. The second annual report was published 
in the Federal Register on October 22, 2010 (75 FR 65340) after 
Secretarial review.
    In March 2011, NQF submitted the third annual report to Congress 
and Secretary of HHS. The third annual report, which covers March 1, 
2010 through February 28, 2011, was published in the Federal Register 
on September 7, 2011 (76 FR 55474) after Secretarial review.
    In March 2012, NQF submitted its fourth annual report to Congress 
and the Secretary. The report covers the period of performance of 
January 14, 2011 through January 13, 2012. The fourth annual report was 
published in the Federal Register on September 14, 2012 (77 FR 56920) 
after Secretarial review.
    In March 2013, NQF submitted its fifth annual report to Congress 
and the Secretary. This report covers the period of performance of 
January 14, 2012 through December 31, 2012. The fifth annual report was 
published in the Federal Register on August 1, 2013 (78 FR 46696) after 
Secretarial review.
    In March 2014, NQF submitted its sixth annual report to Congress 
and the Secretary. The report covers the period of performance of 
January 1, 2013 through December 31, 2013. Because the first annual 
report covered only six weeks, there have been six annual reports under 
this five-year contract. This notice complies with the statutory 
requirement for Secretarial review and publication of the fifth NQF 
annual report.

II. NQF Report of 2013 Activities to Congress and the Secretary of the 
Department of Health and Human Services

    This report was funded by the U.S. Department of Health and Human 
Services under contract number: HHSM-500-2012-00009I Task Order 9.

I. Executive Summary

    Over the last six years Congress has passed two statutes (and 
extended one) that call upon HHS to work with a consensus-based entity 
(the ``Entity'') to facilitate multi-stakeholder input into (1) setting 
national priorities for improvement in quality, and (2) recommending 
use of performance measures in federal programs to achieve these 
priorities. The statutes also call upon a consensus-based entity to 
review and endorse a portfolio of standardized performance measures to 
be used by stakeholders in public and private quality improvement and 
accountability programs. The first of these statutes is the 2008 
Medicare Improvements for Patients and Providers Act (MIPPA) (PL 110-
275), which established the responsibilities of the consensus-based 
entity by creating section 1890 of the Social Security Act. The second 
statute is the 2010 Patient Protection and Affordable Care Act (ACA) 
(Pub. L. 111-148), which modified and added to the consensus-based 
entity's responsibilities. The 2013 American Taxpayer Relief Act (Pub. 
L. 112-240) extended funding under the MIPPA statute to the consensus-
based entity through fiscal year 2013. HHS awarded contracts related to 
the consensus-based entity identified in these statutes to the National 
Quality Forum (NQF).
    These laws specifically charge the Entity to report annually on its 
work. As amended by the above laws, the Social Security Act (the Act)--
specifically section 1890(b)(5)(A)--also mandates that the entity 
report to Congress and the Secretary of the Department of Health and 
Human Services (HHS) no later than March 1st of each year. The report 
must include descriptions of: (1) How NQF has implemented quality and 
efficiency measurement initiatives under the Act and coordinated these 
initiatives with those implemented by other payers; (2) NQF's 
recommendations with respect to activities conducted under the Act ; 
(3) NQF's performance of the duties required under its contract with 
HHS; (4) gaps in endorsed quality and efficiency measures that NQF has 
identified, including measures that are within priority areas 
identified by the Secretary under HHS' national strategy; (5) areas in 
which evidence is insufficient to support endorsement of measures in 
priority areas identified by the National Quality Strategy, and where 
targeted research may address such gaps, and (6) the matters described 
in clauses (i) and (ii) of paragraph (7)(A) of section 1890(b).\1\
    This fifth Annual Report highlight's NQF's work conducted between 
January 14, 2013 and December 31, 2013 related to these statutes and 
conducted under a federal contract with the U.S. Department of Health 
and Human Services. The deliverables produced under contract in 2013 
are referenced throughout this report, and a full list is included in 
Appendix A.

Recommendations on the National Quality Strategy and Priorities

    Section 1890(b)(1) of the Social Security Act (the Act), mandates 
that the consensus-based entity (CBE) also required under section 1890 
of the Act shall ``synthesize evidence and convene key stakeholders to 
make recommendations . . . on an integrated national strategy and 
priorities for healthcare performance measurement in all applicable 
settings.'' In making such recommendations, the entity shall ensure 
that priority is given to measures that address the healthcare provided 
to patients with prevalent, high-cost chronic diseases, that focus on 
the greatest potential for improving the quality, efficiency, and 
patient-centeredness of healthcare, and that may be implemented rapidly 
due to existing evidence and standards of care. In addition, the entity 
will take into account measures that may assist consumers and patients 
in making informed healthcare decisions, address health disparities 
across groups and areas, and address the continuum of care a patient 
receives, including services furnished by multiple healthcare providers 
or practitioners and across multiple settings.
    In 2010, at the request of HHS, the NQF-convened National 
Priorities Partnership (NPP) provided input that helped shape the 
initial version of the National Quality Strategy (NQS).\2\ The NQS was 
released in March 2011, setting forth a cohesive roadmap for achieving 
better, more affordable care, and better health. Upon the release of 
the NQS, HHS accentuated the word `national' in its title, emphasizing 
that healthcare stakeholders across the

[[Page 41566]]

country, both public and private, all play a role in making the NQS a 
success.
    NQF has continued to further the NQS by convening diverse 
stakeholder groups to reach consensus on key strategies for 
improvement. In 2013, NQF began work in several emerging areas of 
importance that address the National Quality Strategy, such as how to 
improve population health within communities; how consumers can 
leverage quality information to make informed healthcare coverage 
decisions; and how to dramatically improve patient safety in high-
priority areas.

Quality and Efficiency Measurement Initiatives (Performance Measures)

    Under section 1890(b)(2) and (3) of the Act, the entity must 
provide for the endorsement of standardized healthcare performance 
measures. The endorsement process shall consider whether measures are 
evidence-based, reliable, valid, verifiable, relevant to enhanced 
health outcomes, actionable at the caregiver level, feasible for 
collecting and reporting data, responsive to variations in patient 
characteristics, and consistent across healthcare providers. In 
addition, the entity must maintain endorsed measures, including 
retiring obsolete measures and bringing other measures up to date.
    Since its inception in 1999, NQF has developed a portfolio of 
approximately 700 NQF-endorsed measures which are in widespread use 
across an array of settings. In concert with others, the work of NQF 
has contributed to a more information-rich healthcare system, and 
demonstrated that measures--particularly in tandem with delivery 
changes and payment reform--can lead to improvement in performance.
    Over the past several years, NQF, working in partnership with HHS 
and others, has worked to evolve the science of performance measurement 
through more rigorous evaluation criteria. This effort has included 
placing greater emphasis on evidence and a clear link to outcomes; a 
greater focus on addressing key gaps in care, including care 
coordination and patient experience; and a requirement that testing of 
measures demonstrates their reliability and validity. NQF also has laid 
the foundation for the next generation of measures by providing 
guidance on composite measurement; patient-reported outcome measures; 
electronic, or eMeasures; and measures that evaluate complex but 
important areas such as resource use and population health.
    Across six HHS-funded projects in 2013, NQF added 27 measures to 
its portfolio. During 2013, NQF also removed 95 measures from its 
portfolio for a variety of reasons: Measures no longer met endorsement 
criteria; measures were harmonized with other similar, competing 
measures; measure developers chose to retire measures they no longer 
wished to maintain; or measures ``topped out,'' by consistently 
performing at the highest level.
    Since September 2013, HHS has awarded to NQF 11 additional measure 
endorsement projects, touching on topics such as admissions and 
readmissions, cost and resource use, endocrine, cardiovascular, care 
coordination, and person- and family-centered care, among others. NQF 
has begun seating expert steering committees for each project, as well 
as issuing calls for measures to be reviewed and considered for 
endorsement.

Stakeholder Recommendations on Quality and Efficiency Measures and 
National Priorities

    Under section 1890A of the Act, HHS is required to establish a pre-
rulemaking process under which a consensus-based entity (currently NQF) 
would convene multi-stakeholder groups to provide input to the 
Secretary on the selection of quality and efficiency measures for use 
in certain federal programs. The list of quality and efficiency 
measures HHS is considering for selection is to be publicly published 
no later than December 1 of each year. No later than February 1 of each 
year, NQF is to report the input of the multi-stakeholder groups, which 
will be considered by HHS in the selection of quality and efficiency 
measures.
    The Measure Applications Partnership (MAP) is a public-private 
partnership convened by NQF and created to provide input to HHS on the 
selection of performance measures for more than twenty federal public 
reporting and performance-based payment programs. The MAP provides a 
unique opportunity for public- and private-sector leaders to develop 
and then seek broad review and comment on a future-focused performance 
measurement strategy, as well as provide shorter-term recommendations 
for that strategy on an annual basis. The MAP strives to offer 
recommendations that apply to and are coordinated across settings of 
care; federal, state, and private programs; levels of attribution and 
measurement analysis; payer type; and points in time.
    In 2013, HHS requested that MAP focus on an array of projects 
including recommending measures for federal public reporting and 
payment programs, developing ``families of measures'' (groups of 
measures selected to work together across settings of care in pursuit 
of specific healthcare improvement goals) for high-priority areas, and 
providing input on measures for vulnerable populations, including 
Medicare-Medicaid enrollees and adults enrolled in Medicaid.

Gaps in Endorsed Quality and Efficiency Measures and Evidence and 
Targeted Research Needs

    Under section 1890(b)(5)(iv) of the Act, the entity is required to 
describe gaps in endorsed quality and efficiency measures, including 
measures within priority areas identified by HHS under the agency's 
National Quality Strategy, and where quality and efficiency measures 
are unavailable or inadequate to identify or address such gaps. Under 
section 1890(b)(5)(v) of the Act, the entity is also required to 
describe areas in which evidence is insufficient to support endorsement 
of quality and efficiency measures in priority areas identified by the 
Secretary under the National Quality Strategy and where targeted 
research may address such gaps.
    NQF continued in 2013 to address the need to fill measurement gaps 
by building on and supplementing the analytic work that informed a 2012 
Measure Gap Analysis Report. Through both the MAP and its expert 
committees convened to assess measures for endorsement, NQF took 
initial steps to encourage gap-filling by moving toward prioritization 
of gap areas, offering more detailed suggestions for measure 
development, and involving measure developers in discussions about 
gaps.
    In an effort to get more specific and detailed guidance to measure 
developers with respect to key measurement gap areas, HHS requested in 
2013 that NQF recommend priorities for performance measurement 
development across five topics areas specified by HHS, including:
     Adult Immunization--identifying critical areas for 
performance measurement to optimize vaccination rates and outcomes 
across adult populations;
     Alzheimer's Disease and Related Dementias--targeting a 
high-impact condition with complex medical and social implications that 
impact patients, their families, and their caregivers;
     Care Coordination--focusing on team-based care and 
coordination between providers of primary care and community-based 
services in the context of the ``health neighborhood'';
     Health Workforce--emphasizing the role of the workforce in 
prevention and

[[Page 41567]]

care coordination, linkages between healthcare and community-based 
services, and workforce deployment; and
     Person-Centered Care and Outcomes--considering measures 
that are most important to patients--particularly patient-reported 
outcomes--and how to advance them through health information 
technology.

II. Recommendations on the National Quality Strategy and Priorities

    Section 1890(b)(1) of the Social Security Act (the Act), mandates 
that the consensus-based entity (CBE) also required under section 1890 
of the Act shall ``synthesize evidence and convene key stakeholders to 
make recommendations . . . on an integrated national strategy and 
priorities for healthcare performance measurement in all applicable 
settings.'' In making such recommendations, the entity shall ensure 
that priority is given to measures that address the healthcare provided 
to patients with prevalent, high-cost chronic diseases, that focus on 
the greatest potential for improving the quality, efficiency, and 
patient-centeredness of healthcare, and that may be implemented rapidly 
due to existing evidence and standards of care. In addition, the entity 
will take into account measures that may assist consumers and patients 
in making informed healthcare decisions, address health disparities 
across groups and areas, and address the continuum of care a patient 
receives, including services furnished by multiple healthcare providers 
or practitioners and across multiple settings.
    In 2010, at the request of HHS, the NQF-convened National 
Priorities Partnership (NPP) provided input that helped shape the 
initial version of the National Quality Strategy (NQS).\3\ The NQS was 
released in March 2011, setting forth a cohesive roadmap for achieving 
better, more affordable care, and better health. Upon the release of 
the NQS, HHS accentuated the word `national' in its title, emphasizing 
that healthcare stakeholders across the country, both public and 
private, all play a role in making the NQS a success.
    NQF has continued to further the NQS by convening diverse 
stakeholder groups to reach consensus on key strategies for 
improvement. In 2013, NQF began work in several emerging areas of 
importance that address the National Quality Strategy, such as how to 
improve population health within communities; how consumers can 
leverage quality information to make informed healthcare coverage 
decisions; and how to dramatically improve patient safety in high-
priority areas. Activities in these areas are discussed below.

Improving Population Health Within Communities

    The National Quality Strategy's population health aim focuses on:

``Improv[ing] the health of the U.S. population by supporting proven 
interventions to address behavioral, social, and environmental 
determinants of health in addition to delivering higher-quality 
care.''

One of the NQS' six priorities specifically emphasizes:

``Working with communities to promote wide use of best practices to 
enable healthy living.''

    With the expansion of coverage due to the ACA, the Federal 
government has an opportunity to meaningfully coordinate its 
improvement efforts with those of local communities in order to better 
integrate and align medical care and population health. If such efforts 
are effective, the nation's health will be improved and costs will be 
lowered. To support these efforts, NQF conducted an environmental scan 
of frameworks, initiatives, tools, data, and measures that can provide 
the foundation for developing an evidence-based framework to be used by 
communities to improve population health. This framework is intended to 
provide guidance in answering questions such as:
     How can multi-stakeholder groups come together to address 
community health improvement?
     Which individuals and organizations should be at the 
table?
     What processes and methods should communities use to 
assess their health?
     What data are available to assess, analyze, and address 
community health needs, and measure improvement?
     What incentives exist that can drive alignment and 
coordination to improve community health?
     How can communities advance more affordable care by 
achieving greater alignment, efficiency, and cost savings?

This framework will also identify key drivers of population health 
across communities; opportunities to align public- and private-sector 
programs as well as federal programs to reduce measurement burden; and 
measures to drive improvement in health.
    The project's Steering Committee met in January 2014 to discuss the 
results of the environmental scan and how it can be leveraged to 
develop a framework. This initial work is part of a three-year effort 
that ultimately will result in an action-oriented guide that 
communities can use to implement the framework and improve population 
health.

Health Insurance Exchange Quality Rating System

    Under the statutory provision that the consensus-based entity will 
``take into account measures that may assist consumers and patients in 
making informed healthcare decisions,'' HHS directed NQF to convene 
multi-stakeholder groups to provide input and comment on the 
hierarchical structure and organization of a Quality Rating System 
(QRS), as well as proposed quality and efficiency measures that will 
form a core measure set for the QRS. The measures--which will be 
publicly reported beginning in 2016--will help consumers select plans 
through the new Health Insurance Exchanges established by the 
Affordable Care Act.
    The review and provision of input on the proposed core measures and 
organization of information for the QRS is being carried out by NQF's 
Measure Applications Partnership (MAP). The MAP is made up of 
stakeholders from a wide array of healthcare sectors and 10 federal 
agencies, as well as 110 subject matter experts, tasked with 
recommending measures for federal public reporting, payment, and other 
programs to enhance healthcare value. The MAP convened the QRS Task 
Force in November 2013 to finalize the task force's decision-making 
framework, provide input on the proposed measures for the family and 
child measure core sets, and comment on the structure of the QRS. The 
task force also discussed the highest leverage opportunities for 
measurement within the health insurance exchange marketplaces and 
developed an ideal organization of measures to best support consumer 
decision-making. The task force met again in December 2013 and 
finalized recommendations to the MAP Coordinating Committee on the 
proposed structure and measures for the QRS for submission in January 
2014.\4\

Supporting HHS' Partnership for Patients

    Finally, NQF is leveraging its membership and relationships with 
key stakeholders across the healthcare field to further mobilize 
private sector action in support of HHS' Partnership for Patients,\5\ 
an initiative started in spring 2011 to improve patient safety across 
the country. Specifically, in 2013 NQF formed three Action Teams--
established teams tasked with developing and acting on specific goals 
aligned with the NQS safety priority--

[[Page 41568]]

to address high-priority areas for improvement, including maternity 
care, patient and family engagement, and readmissions. The Action Teams 
largely comprise diverse national organizations that have members or 
chapters in communities across the country. Through coordination at the 
national level, Action Teams spur changes to the delivery system at the 
local level. Previous Action Teams formed by NQF have worked on 
improving maternity care and reducing readmissions, but in late 2013, 
these Teams committed to focusing on specific goals, including:

     Reducing early elective deliveries;
     Reducing readmissions for complex and vulnerable 
populations; and
     Engaging patients and families in health systems 
improvement.

In partnership with the Action Teams, NQF will hold four quarterly 
meetings and develop four impact reports in 2014 that call out 
innovative ideas and best practices that have the potential to 
accelerate change.

III. Quality and Efficiency Measurement Initiatives (Performance 
Measures)

    Under section 1890(b)(2) and (3) of the Act, the entity must 
provide for the endorsement of standardized health care performance 
measures. The endorsement process shall consider whether measures are 
evidence-based, reliable, valid, verifiable, relevant to enhanced 
health outcomes, actionable at the caregiver level, feasible for 
collecting and reporting data, responsive to variations in patient 
characteristics, and consistent across healthcare providers. In 
addition, the entity must maintain endorsed measures, including 
retiring obsolete measures and bringing other measures up to date.
    Standardized healthcare performance measures are used by a range of 
healthcare stakeholders for a variety of purposes. Measures help 
clinicians, hospitals, and other providers understand whether the care 
they provide their patients is optimal and appropriate, and if not, 
where to focus their efforts to improve. Public and private payers also 
use measures for feedback and benchmarking purposes, public reporting, 
and incentive-based payment. Lastly, measures are an essential part of 
making the cost and quality of healthcare more transparent to all, 
particularly for those who receive care or help make care decisions for 
loved ones.
    Working with a variety of stakeholders to build consensus, NQF 
reviews and endorses healthcare performance measures that underpin 
federal and private-sector initiatives focused on enhancing the value 
of healthcare services. Since its inception in 1999, NQF has developed 
a portfolio of approximately 700 NQF-endorsed measures which are in 
widespread use across an array of settings. In concert with others, the 
work of NQF has contributed to a more information-rich healthcare 
system, and demonstrated that measures--particularly in tandem with 
delivery changes and payment reform--can lead to improvement in 
performance.
    Over the past several years, NQF, in concert with HHS and others, 
has worked to evolve the science of performance measurement through 
more rigorous evaluation criteria. This effort has included placing 
greater emphasis on evidence and a clear link to outcomes; a greater 
focus on addressing key gaps in care, including care coordination and 
patient experience; and a requirement that testing of measures 
demonstrates their reliability and validity. NQF also has laid the 
foundation for the next generation of measures by providing guidance on 
composite measurement, patient-reported outcome measures, electronic or 
eMeasures, and measures that evaluate complex but important areas such 
as resource use and population health.

Current State of NQF Measures Portfolio: Constricting and Expanding To 
Meet Evolving Needs

    NQF's measure ``maintenance'' process--where endorsed measures are 
re-evaluated against current criteria and reviewed alongside newly 
submitted but not yet endorsed measures--ensures that the measure 
portfolio contains ``best-in class'' measures across a variety of 
clinical and cross-cutting topic areas. Working with expert 
committees,\6\ NQF undertakes three essential actions to keep its 
endorsed measure portfolio relevant. First, the expert committees 
review both previously endorsed and new measures in a particular topic 
area to determine which measures deserve to be endorsed or re-endorsed. 
In addition, as the expert committees review measures for endorsement, 
they also recommend removing from the portfolio--or putting into 
``reserve status'' \7\--measures that consistently show improvement at 
the highest levels or ``top out.'' This culling of measures ensures 
that time is spent measuring concepts in need of improvement rather 
than measuring concepts where widespread success has already been 
achieved.
    Finally, NQF also works with stewards and developers who create 
measures, in order to ``harmonize'' related or near-identical measures 
and eliminate nuanced differences. Harmonization is critical to 
reducing measurement burden for providers, who may be inundated with 
various misaligned measurement requests. Successful harmonization may 
result in fewer endorsed measures for providers to report and for 
payers and consumers to interpret. Where appropriate, NQF works with 
measure developers to replace existing process measures with more 
meaningful outcome measures.
    Across six HHS-funded projects in 2013, NQF added 27 measures to 
its portfolio. This contrasts to 301 measures endorsed in 2012 across 
16 HHS-funded projects. The significant difference in endorsed measures 
between 2012 and 2013 can be attributed to the fact that the 2013 work 
was primarily conducted within a contract that was nearing completion. 
New measure endorsement projects were awarded under a new contracting 
vehicle in September 2013. During 2013, NQF also removed 95 measures 
from its portfolio for a variety of reasons: Measures no longer met 
endorsement criteria; measures were harmonized with other similar, 
competing measures; measure developers chose to retire measures they no 
longer wished to maintain; or measures ``topped out,'' by consistently 
performing at the highest level.
    While NQF pursues strategies to make its measure portfolio 
appropriately lean, it also aggressively seeks measures from the field 
that will help to fill known measure gaps and to align with the NQS 
goals. Several important factors motivate NQF to expand its portfolio, 
including the need for eMeasures; measures that are applicable to 
multiple clinical specialties and settings of care; measures which 
assist in the evaluation of new payment models (e.g., bundled payment); 
and the need for more advanced measures that help close cross-cutting 
gaps in areas such as care coordination and patient-reported outcomes. 
The measure portfolio reflects the combined ``dynamic yet static'' 
effect of these strategies: Although the portfolio frequently changes 
due to new measures cycling in and older measures cycling out, the 
relative number of endorsed measures remained steady in 2013.
    Furthermore, a diverse set of measure developers, ranging from 
medical specialty societies to hospital systems to government agencies, 
have had measures endorsed through NQF's consensus development process. 
While 69 developers have made significant contributions to the 
portfolio, seven

[[Page 41569]]

measure developers account for 64 percent of NQF's portfolio:

                   Top Developers of Endorsed Measures
------------------------------------------------------------------------
                                                            Percent of
        Measure steward/developer            Number of         total
                                             measures        portfolio
------------------------------------------------------------------------
1. Centers for Medicare & Medicaid                   117              17
 Services...............................
2. National Committee for Quality                    104              15
 Assurance (NCQA).......................
3. Physician Consortium for Performance               94              14
 Improvement (PCPI).....................
4. Agency for Healthcare Research and                 56               8
 Quality (AHRQ).........................
5. Resolution Health, Inc...............              23               3
6. The Joint Commission.................              22               3
7. ActiveHealth Management..............              22               3
------------------------------------------------------------------------

Measure Endorsement Accomplishments

    In 2013, NQF completed work on six HHS-funded measure endorsement 
projects--endorsing 27 total measures. These measures included 11 new 
measures and 16 measures that the NQF expert committees concluded could 
maintain their previous endorsement after being reviewed against the 
NQF measure evaluation criteria and compared to new evidence or 
competing measures.
    The measures endorsed by NQF in 2013 align with needs prioritized 
in the NQS and address several critical areas, including pulmonary and 
critical care, infectious disease, neurology, and patient safety.
    Measure highlights include the following:
    Pulmonary and critical care measures. Lung disease--including 
asthma, chronic obstructive pulmonary disease (COPD), and pneumonia--
affects some 33 million Americans and is the third leading cause of 
death in the United States.\8\ Critical care units often bear the 
burden of treating people with these and other conditions. Each year, 
more than five million people are admitted to intensive care units 
(ICUs) suffering from respiratory distress or failure, sepsis, and 
heart disease or failure. In 2013, NQF endorsed a measure addressing 
mortality rates for patients hospitalized with chronic obstructive 
pulmonary disease (COPD), as well as two measures focused on 
readmission rates for patients hospitalized with COPD and pneumonia.
    Neurology measures. Neurological conditions and injuries affect 
millions of Americans each year, taking a tremendous toll on patients, 
families, and caregivers, and costing billions of dollars in treatment, 
rehabilitation, and lost or reduced earnings. An estimated 5.4 million 
Americans have Alzheimer's disease, accounting for 70 percent of the 
cases of dementia in the country and $130 billion in Medicare and 
Medicaid spending in 2011.9 10 11 Furthermore, epilepsy and 
Parkinson's disease together affect three million Americans and cost 
$15.5 billion and $25 billion in healthcare costs each year, 
respectively.12 13 In 2013, NQF endorsed five measures 
related to diagnostic imaging and care for dementia and epilepsy.
    Infectious disease measures. Many infectious diseases have been 
controlled or eradicated through the use of vaccines and advanced 
medicine, yet many others are still responsible for widespread 
morbidity and mortality as well as rising healthcare costs. In fact, 
hospital charges for infectious disease averaged $96 billion per year 
with an average 4.5 million hospital days per year in 2008.\14\ In 
2013, NQF endorsed 16 infectious disease measures focused on an array 
of conditions, including sepsis and septic shock, appropriate treatment 
for upper respiratory infections, screening for tuberculosis and 
sexually transmitted infections in HIV/AIDs patients, and vaccination 
and treatment for hepatitis C.
    Patient safety measures. The Centers for Disease Control and 
Prevention estimates that healthcare-acquired infections potentially 
cost U.S. hospitals more than $31 billion per year.\15\ These costs are 
passed on in a number of ways, including insurance premiums, taxes, or 
lost work wages. Proactively addressing medical errors and unsafe care 
will help protect patients from harm, lead to more effective and 
equitable care, and can help reduce costs. In 2013, through its patient 
safety complications endorsement project, NQF endorsed two measures 
related to patient falls, including fall rates and falls that resulted 
in injury.

Advancing Measurement Science

    NQF was also asked to provide guidance to the field on emerging 
areas of importance, and as a result completed two reports--Composite 
Performance Measure Evaluation Guidance \16\ and eMeasure Feasibility 
Assessment,\17\ described below.
    Evaluating composite measures. NQF undertook an HHS-funded project 
focused on providing guidance about composite measures--which combine 
information on multiple individual performance measures into one 
summary measure. Such measures can provide a way for payers and 
patients to get a high-level, comprehensive sense of performance in a 
given area, while giving providers a look at the strengths and 
weaknesses of the care they are providing. However, composite measures 
are complex, and the methods used to construct such measures affect the 
reliability, validity, and usefulness of the measure and require some 
unique considerations for testing and analysis. Accordingly, NQF 
convened a Technical Expert Panel that produced a final report offering 
guidance to Steering Committees tasked with evaluating composite 
measures. The primary recommendations that came out of the report 
indicate that while composite measures may be evaluated against current 
NQF measure evaluation criteria, they must also be subject to two 
additional sub-criteria addressing evidence and reliability and 
validity (further explanation can be found in Table 1 of the final 
report \18\). NQF did not endorse any composite measures in 2013.
    eMeasure feasibility assessment. As quality measurement shifts to 
using measures derived from electronic health records (EHRs), there is 
a need for more clarity about the testing required to assure that 
eMeasures can be used for a range of accountability applications. In 
response, a report from NQF identified a set of principles and criteria 
to ensure adequate feasibility testing for new and retooled eMeasures 
moving forward. This final report provides important guidance that can 
shape future eMeasure development, as well as product development and 
certification requirements. Specifically, the report

[[Page 41570]]

included seven feasibility recommendations, including the need to:

1. Assess feasibility throughout eMeasure development
2. Develop a framework for feasibility assessment
3. Validate data element feasibility scoring
4. Create a data element feasibility repository
5. Use results of feasibility assessment to inform NQF evaluation for 
endorsement
6. Use NQF composite performance measurement guidance to inform 
eMeasure developers
7. Promote greater collaboration between eMeasure developers and 
implementers

    A complete listing of measurement projects undertaken by NQF in 
2013 under contract with HHS is available in Appendix A, including the 
11 new endorsement projects that were awarded in fall 2013. Individual 
measures may be found on the NQF Web site using the Quality Positioning 
System (QPS),\19\ NQF's search tool for endorsed measures. Please note 
that no eMeasures were endorsed in 2013.

New Endorsement Work Ahead

    Since September 2013, HHS has awarded to NQF several additional 
measure endorsement projects, touching on topics such as admissions and 
readmissions, cost and resource use, endocrine, cardiovascular, care 
coordination, and person- and family-centered care, among others. NQF 
has begun seating expert steering committees for each project, as well 
as issuing calls for measures to be reviewed and considered for 
endorsement.
    In addition, NQF has begun work on two other measure-related 
projects. One focuses on episode groupers, which create condition-
specific episodes of care from administration claims data, which can be 
useful in deciding how best to group costs per episode. In turn, these 
groupers can help the healthcare community make meaningful assessments 
and comparisons about the cost and amount of healthcare resources used.
    In the episode grouper project, NQF seeks to:
     Define the characteristics of an episode grouper in 
comparison to other systems, including classification or risk 
adjustment systems;
     Review (and modify as needed) existing NQF endorsement 
criteria and guidance, and/or provide additional recommendations for 
episode grouper evaluation;
     Examine the necessary submission elements for the 
evaluation of an episode grouper; and
     Review best practices for the construction of an episode 
grouper.
    NQF is working to seat an expert steering committee for this work, 
and will hold an in-person meeting in 2014.
    Through the second measurement science project, NQF is bringing 
together expert stakeholders to develop a set of recommendations 
focused on risk adjustment for performance measures--the process of 
controlling for intrinsic patient factors that could influence 
outcomes. For example, risk adjustment allows for fair comparisons 
between two providers who treat elderly, sicker patients and younger, 
healthier patients, respectively. These recommendations will 
specifically address if, when, and how resource use performance 
measures should be adjusted for socioeconomic status (SES), race, and 
ethnicity. The recommendations will also address whether NQF's measure 
evaluation criteria--which currently indicate that such measures not be 
risk adjusted but instead stratified (i.e., split in a way that shows 
differences between two or more groups) for factors related to 
disparities in care--should be revised. NQF finalized the composition 
of a steering committee to guide this project in December 2013.

Patient Safety Event Reporting

    For more than ten years, both NQF and the Agency for Healthcare 
Research and Quality (AHRQ) have worked to find a standardized approach 
for reporting to enable shared learning across the country on how to 
reduce adverse events. NQF's list of Serious Reportable Events (SRE's) 
first published in 2002, has helped raise awareness and stimulate 
action around preventable adverse event that should be reported. The 
Patient Safety and Quality Improvement Act of 2005 advanced reporting 
further by authorizing the development of common and consistent 
definitions and standardized formats to collect, collate, and analyze 
patient safety events occurring within and across healthcare providers. 
AHRQ developed the Common Formats--a standardized method for collection 
and compilation of information about patient safety events occurring in 
the United States, including Serious Reportable Events--to 
operationalize those provisions of the Act.
    To ensure the Common Formats are feasible for use in the field, 
AHRQ has contracted with NQF to implement a process that ensures broad 
stakeholder input on new Common Formats modules developed by AHRQ. 
Having collected comments in previous years, NQF is now tasked with 
collecting comments on methods for further refining the Common Formats. 
A commenting tool will be available to stakeholders in 2014 pending a 
launch date decision from AHRQ.

Work Related to Facilitating eMeasurement

    Developed by NQF, the Quality Data Model (QDM) is an ``information 
model'' that provides a way to describe clinical concepts (for example, 
medications ordered or dispensed for patients with coronary artery 
disease) in a structured and standard format that can be interpreted by 
clinical information systems. The QDM is also a key component in the 
development of electronic clinical quality measures, in that it 
provides the basic logic to articulate quality measure criteria. For 
several years, NQF has worked with HHS to further develop and refine 
the QDM. NQF has now worked with QDM stakeholders to transition the 
development and maintenance of the QDM to a Federally Funded Research 
and Development Center (FFRDC). In preparation, NQF hosted four 
webinars that provided guidance and updates throughout the transition, 
which was completed in December 2013.

IV. Stakeholder Recommendations on Quality and Efficiency Measures and 
National Priorities

Measure Applications Partnership

    Under section 1890A of the Act, HHS is required to establish a pre-
rulemaking process under which a consensus-based entity (currently NQF) 
would convene multi-stakeholder groups to provide input to the 
Secretary on the selection of quality and efficiency measures for use 
in certain federal programs. The list of quality and efficiency 
measures HHS is considering for selection is to be publicly published 
no later than December 1 of each year. No later than February 1 of each 
year, NQF is to report the input of the multi-stakeholder groups, which 
will be considered by HHS in the selection of quality and efficiency 
measures.
    The Measure Applications Partnership (MAP) is a public-private 
partnership convened by NQF, as mandated by the ACA (Pub. L. 111-148, 
section 3014). The MAP was created to provide input to HHS on the 
selection of performance measures for more than twenty federal public 
reporting and performance-based payment programs. Launched in the 
spring of 2011, the

[[Page 41571]]

MAP is composed of representatives from more than 60 major private-
sector stakeholder organizations, nine federal agencies, and 40 
individual technical experts. For detailed information regarding the 
MAP representatives, criteria for selection on the MAP and length of 
their service, please see the appendices.
    The MAP is an innovation in the regulatory sphere; it provides a 
forum to get the private and public sectors on the same page with 
respect to use of measures to enhance healthcare value. In addition, 
the MAP is an interactive and inclusive vehicle by which the federal 
government can solicit critical feedback from stakeholders--
particularly consumers and purchasers--regarding measures used in 
federal public reporting and payment programs. This approach augments 
traditional rulemaking, allowing the opportunity for substantive input 
to HHS in advance of rules being issued. Additionally, the MAP provides 
a unique opportunity for public- and private-sector leaders to develop 
and then broadly review and comment on a future-focused performance 
measurement strategy, as well as provide shorter-term recommendations 
for that strategy on an annual basis. The MAP strives to offer 
recommendations that apply to and are coordinated across settings of 
care; federal, state, and private programs; levels of attribution and 
measurement analysis; payer type; and points in time.
    In 2013, the MAP took on several diverse tasks focused on 
recommending measures for federal public reporting and payment 
programs, developing ``families of measures'' (groups of measures 
selected to work together across settings of care in pursuit of 
specific healthcare improvement goals) for high-priority areas, and 
providing input on measures for vulnerable populations, including dual 
Medicare-Medicaid enrollees and adults enrolled in Medicaid. 
Specifically:

2013 Pre-Rulemaking Input

    On December 1, 2012, the MAP received and began reviewing a list of 
more than 500 measures under consideration by HHS for use in more than 
twenty Medicare programs covering clinician, hospital, and post-acute 
care/long-term care settings. The MAP Pre-Rulemaking Report: 2013 
Recommendations on Measures Under Consideration by HHS \20\ represents 
the MAP's second annual round of input regarding performance measures 
under consideration for use in federal programs.
    In this pre-rulemaking 2013 report \21\ the MAP recommended to HHS 
inclusion of 141 measures within 20-plus Medicare programs and 
supported the direction of another 166 measures. The MAP's ``support 
direction'' recommendations are contingent on further development, 
testing, and/or endorsement. The MAP did not support 165 measures under 
consideration. Further, the MAP recommended phased removal of 64 
measures, and retirement of an additional six measures.
    The MAP Clinician and Hospital Workgroups developed guiding 
principles to facilitate their decisions about the application of 
measures to specific programs rather than offering recommendations on 
individual measures. The guiding principles (included in the appendix 
\22\ of the final report) are not absolute rules, and are intended to 
complement statutory and regulatory requirements and the broader MAP 
Measure Selection Criteria. Workgroup members, including Centers for 
Medicare & Medicaid Services (CMS) representatives, found the 
principles to be valuable for thinking through measure selection for 
specific programs while also accounting for the inter-relationships 
among the programs.
    In its 2013 pre-rulemaking report, the MAP noted several themes for 
future consideration that emerged across all 20 Medicare programs 
during the pre-rulemaking cycle including:
     System-level measurement (e.g., at the level of health 
plans, accountable care organizations, integrated delivery systems) can 
be a catalyst for comprehensively assessing care across settings and 
populations and addressing all aspects of the NQS three-part aim: 
Better Care; Healthy People/Healthy Communities; and Affordable Care.
     As program incentive structures evolve from pay-for-
reporting to pay-for-performance, it is increasingly important that 
performance measures meet high standards for validity and reliability 
so that providers are not misclassified.
     Shared accountability for healthcare delivery and 
engagement of community and social supports systems is needed to 
address diverse needs and fragmented care, particularly of vulnerable 
populations.
     To capture the value of healthcare services provided, 
measures of clinical quality, particularly outcomes, should be linked 
to cost measures. All stakeholders should be cognizant of the costs of 
care.

2014 Pre-Rulemaking Input

    The MAP also began work on the 2014 Pre-Rulemaking Report. In 
December 2013, the four MAP work groups--Clinician, Dual Eligible 
Beneficiaries, Hospital, and Post-Acute Care/Long-Term Care--met 
individually to review and provide input to the MAP Coordinating 
Committee on measure sets for use in federal programs addressing their 
respective populations. A final report and recommendations on measures 
will be issued in 2014.

Families of Measures: Affordability, Person- and Family-Centered Care, 
and Population Health

    In 2013, HHS again tasked the MAP to identify new families of 
measures--groups of measures selected to work together across settings 
of care in pursuit of specific healthcare improvement goals--in three 
high-priority areas that relate to NQS priorities: Affordability, 
person- and family-centered care, and population health. The 
Affordability Task Force has since been formed, and members are now 
working to develop consensus-based definitions of affordability. NQF 
also held a public comment period in November 2013 soliciting input on 
how to define affordability, as well as on what is most important to 
measure. In 2014, the MAP will finalize Task Forces for the Person- and 
Family-Centered Care and Population Health topics, and begin 
identifying appropriate measures.

Family of Measures for Dual Eligible Beneficiaries: Preliminary 
Findings From the MAP Dual Eligible Beneficiaries Workgroup

    Efforts to better integrate care for Medicare-Medicaid enrollees 
have gained significant momentum since the Secretary established the 
Federal Coordinated Health Care Office (Medicare-Medicaid Coordination 
Office) as required by the Affordable Care Act. Generally, Medicare-
Medicaid enrollees are people who are enrolled in both Medicare and 
Medicaid and are sometimes referred to as ``dual eligibles.'' The 
selection and use of appropriate measures are critical to satisfy the 
need for information about beneficiary experience for this group. 
Beginning in 2011, HHS charged the MAP with providing input on the use 
of performance measures to assess and improve the quality of care 
delivered to Medicare-Medicaid enrollees. The MAP has continued to 
explore this topic and has completed a series of reports to HHS that 
present sets of available measures appropriate for use in this 
population.
    In July 2013, the MAP issued a report that recommended a family of 
measures for Medicare-Medicaid enrollees and included a discussion of 
the issues in quality measurement for individuals

[[Page 41572]]

with behavioral health conditions. Both public and private sector 
measure users could reference and implement this family, leading to 
more consistent information that helps healthcare performance measure 
to be more transparent and easier to interpret.
    The MAP Dual Eligible Beneficiaries Workgroup considered the 
following properties when assessing an identified measure's 
appropriateness for inclusion in the family.
     NQF endorsement: Include NQF-endorsed[supreg] measures 
because they have met criteria for importance, scientific rigor, 
feasibility, and usability.
     Potential impact: Include measures with the most power to 
improve health, such as outcome measures, composite measures, and 
cross-cutting measures broadly defined to include a large denominator 
population.
     Improvability: Include measures that target areas in which 
quality improvement would be expected to have a substantial effect or 
address health risks and conditions known to have disparities in care.
     Relevance: Include measures that address health risks and 
conditions that are highly prevalent, severe, costly, or otherwise 
particularly burdensome for the dual eligible population.
     Person-centeredness: Include measures that are meaningful 
and important to consumers, such as those that focus on engagement, 
experience, or other individually-reported outcomes. Person-centered 
care emphasizes access, choice, self-determination, and community 
integration.
     Alignment: Include measures already reported for existing 
measurement programs to minimize participants' data collection and 
reporting burden. Consistent use of measures helps to synchronize 
public- and private-sector programs around the National Quality 
Strategy and to amplify the quality signal.
     Reach: Include measures relevant to a range of care 
settings, provider types, and levels of analysis.
    A measure did not need to fulfill all of the properties to be 
selected. However, to be considered comprehensive, the family of 
measures should encompass all of these characteristics because they are 
particularly important for achieving good results within the Medicare-
Medicaid enrollee population. Stakeholders planning quality measurement 
programs can apply the properties to other measure sets to evaluate 
whether a measure would be appropriate for their use and general 
alignment with MAP principles.
    To compile the family of measures, the workgroup considered the 
universe of measures previously identified by the MAP for use in the 
general Medicare-Medicaid enrollee population or one of its high-need 
subgroups. The Workgroup also reviewed a small number of newly 
developed measures not previously selected. From a starting point of 97 
possible measures, the Workgroup conducted multiple rounds of 
prioritization and ultimately selected 55 measures for inclusion in the 
family. Of these measures, 51 are currently endorsed by NQF and four 
have been submitted for endorsement in NQF's current consensus 
development project for behavioral health.

Identification of Quality Measures for Medicare-Medicaid Enrollees and 
Adults Enrolled in Medicaid

    HHS also asked NQF to convene a multi-stakeholder group via the MAP 
to continue addressing measurement topics related to Medicare-Medicaid 
enrollees and make annual refinements to the previously published 
Family of Measures. NQF will also evaluate opportunities to improve 
alignment and reduce burden associated with overlapping state and 
federal measurement requirements.
    In addition, HHS asked that the MAP provide annual input on the 
Initial Core Set of Health Care Quality Measures for Adults Enrolled in 
Medicaid. The first part of this work, completed in 2013, was informed 
by direct feedback from state Medicaid directors and other 
stakeholders. In October 2013, NQF submitted a final report to HHS 
which detailed the MAP's findings of an expedited review of the Initial 
Core Set of Measures as well as public comment on the findings.
    Since these tasks were awarded, the MAP Dual Eligible Beneficiaries 
Workgroup has met to discuss measuring quality of life, and NQF has 
delivered the first of three quarterly memos to HHS focused on 
strategic issues. NQF staff have also been involved in convening 
activities across the other MAP Workgroups--Clinician, Hospital, and 
Post-Acute Care/Long-Term Care--during pre-rulemaking deliberations to 
ensure all activities related to these populations remain coordinated.

V. Gaps in Endorsed Quality and Efficiency Measures and Evidence and 
Targeted Research Needs

    Under section 1890(b)(5)(iv) of the Act, the entity is required to 
describe gaps in endorsed quality and efficiency measures, including 
measures within priority areas identified by HHS under the agency's 
National Quality Strategy, and where quality and efficiency measures 
are unavailable or inadequate to identify or address such gaps. Under 
section 1890(b)(5)(v) of the Act, the entity is also required to 
describe areas in which evidence is insufficient to support endorsement 
of quality and efficiency measures in priority areas identified by the 
Secretary under the National Quality Strategy and where targeted 
research may address such gaps.

Report From the National Quality Forum: 2012 NQF Measure Gap Analysis

    In February of 2013, NQF completed the 2012 Measure Gap Analysis 
Report \23\ which aimed to provide guidance about where measures do and 
do not exist to help achieve the nation's quality goals. This report 
revealed that discussions of measure gaps remain at a high conceptual 
level, and that more specificity--ideally through a multi-stakeholder 
prioritization process--is needed. While measures currently used in the 
field may address high-priority gap areas, a full assessment of their 
applicability and appropriateness was beyond the scope of this project. 
Existing measures that address identified gaps should be brought forth 
for NQF endorsement to assess their importance, scientific reliability 
and validity, usability, and feasibility before any assessment of value 
or recommendations for use are made. The final report discusses in 
detail measure gaps identified, presented through the lens of the NQS 
triple aim: Better care, healthy people/healthy communities, and 
accessible and affordable care. The identified gaps across these three 
aims were:
     Better care: Patient-reported outcomes; patient-centered 
care and shared decision-making; care coordination and care 
transitions; and care for vulnerable populations;
     Healthy people/healthy communities: Health and well-being; 
preventive care; and childhood measures; and
     Accessible and affordable care: Access to care; healthcare 
affordability, and waste and overuse.

MAP Pre-Rulemaking Input Related to Gap Filling

    NQF continued in 2013 to address the need to fill measurement gaps 
to build on and supplement the analytic work that informed the above 
2012 Measure Gap Analysis Report. NQF, through both the MAP and its 
expert endorsement committees, took initial steps to encourage gap-
filling by moving toward

[[Page 41573]]

prioritization of gap areas, offering more detailed suggestions for 
measure development, and involving measure developers in discussions 
about gaps. However, much work remains to be done by measure 
developers, NQF and many other entities to accelerate closing the gaps.
    During the MAP's pre-rulemaking review of proposed measures 
submitted by HHS in December of 2012, the areas on the MAP's list of 
previously identified gaps were validated with some additional detail 
and nuances. For instance, the Clinician Workgroup indicated that 
measures need to reflect a more diverse set of outpatient conditions; 
the group struggled to find available measures that adequately balance 
issues under the control of individual clinicians versus the larger 
health system. Public commenters generally agreed with the gap areas 
identified on the NQF list, including gaps in:
     Safety: Healthcare-associated infections, medication 
safety, perioperative/procedural safety, pain management, venous 
thromboembolism, falls and mobility, and obstetric adverse events;
     Patient and family engagement: Person-centered 
communication, shared decision making and care planning, advanced 
illness care, and patient-reported measures;
     Healthy living;
     Care coordination: Communication, care transitions, system 
and infrastructure support, and avoidable admissions and readmissions;
     Affordability; and
     Prevention and treatment of leading causes of mortality: 
Primary and secondary prevention, cancer, cardiovascular conditions, 
depression, diabetes, and musculoskeletal conditions.
    Multiple organizations also conveyed a need for better measures on 
diverse topics including care coordination, functional status, 
medication management, and palliative care. Some public commenters 
offered specific recommendations for additional priority gap areas, 
such as prevention and treatment of osteoporosis, and made suggestions 
for updates to the list of previously identified gaps.
    Despite the relatively large number of measures under consideration 
by the MAP, stakeholders indicated that many measure gaps remain. In 
general, the types of gaps raised were consistent with those that the 
MAP has previously identified, and include a need for more outcome 
measures; measures for discrete populations, such as children and the 
underserved; measures that are not specified at the desired level of 
analysis and/or setting;\24\ measures that go beyond a ``checkbox'' 
approach to assess whether high standards of care are being met; a lack 
of composite measures for multifaceted topics; and a relative dearth of 
measures addressing certain specialty areas, such as mental and 
behavioral health. Each of the NQS priority areas remains affected to 
some degree by persistent measure gaps.
    MAP members expressed strong support for NQF playing a coordination 
role in gap-filling and working closely with measure developers early 
in the development process, rather than only as ``referee'' during 
endorsement, while guarding against involvement in measure development. 
One theme from MAP discussions identified a collective need to better 
understand the development pipeline and the cost of stewarding a 
measure to assess barriers to measure development. Subsequent 
discussion touched on the need to create a business case for measure 
development. Another theme was the lack of shared knowledge about which 
measure developers are already working on certain topics which can lead 
to duplicative efforts and inefficient use of resources.
    In an effort to address these issues, NQF has launched a Measure 
Inventory Pipeline, which is a virtual space for developers to share 
information on measure development activities. The Pipeline can display 
data on current and planned measure development, and allows developers 
to share successes and challenges. The Pipeline can also help 
developers connect and collaborate with their peers on development 
ideas, which in turn will promote harmonization and alignment of 
measures. This Pipeline will supplement CMS' existing Measure Pipeline 
and allow developers to more broadly share information with their peers 
across public and private supported development effort.
    Public commenters broadly supported NQF's initiatives to make 
progress on gap-filling. Some public commenters offered recommendations 
for new directions to take in measure development, such as making 
better use of alternate data sources and increasing research in 
important areas where evidence is limited. Several organizations stated 
an explicit desire to assist NQF in its ongoing efforts to address 
measure gaps.
    With respect to MAP 2014 Pre-Rulemaking advice, early review and 
discussion by MAP committees of more than 230 proposed measures in 
December of 2013 showed that a significant proportion of measures under 
HHS consideration related to efficiency and cost reduction, 
corresponding to the NQS priority of making care more affordable. A 
relatively small number of measures under consideration addressed 
person- and family-centered experience and community/population health, 
essential priorities that are underrepresented in terms of quantity of 
current measures. In contrast, the greatest proportion of measures 
addresses the priority area of effective clinical care, which are the 
largest number of measures in NQF's portfolio.

Priority Setting for Health Care Performance Measurement: Addressing 
Performance Gaps in Priority Areas

    In an effort to get more specific and detailed guidance to 
developers with respect to key measurement gap areas, HHS requested in 
2013 that NQF recommend priorities for performance measurement 
development across five topics areas specified by HHS, including:
     Adult Immunization--identifying critical areas for 
performance measurement to optimize vaccination rates and outcomes 
across adult populations;
     Alzheimer's Disease and Related Dementias--targeting a 
high-impact condition with complex medical and social implications that 
impact patients, their families, and their caregivers;
     Care Coordination--focusing on team-based care and 
coordination between providers of primary care and community-based 
services in the context of the ``health neighborhood'';
     Health Workforce--emphasizing the role of the workforce in 
prevention and care coordination, linkages between healthcare and 
community-based services, and workforce deployment; and
     Person-Centered Care and Outcomes--considering measures 
that are most important to patients--particularly patient-reported 
outcomes--and how to advance them through health information 
technology.

To-date, NQF has finalized topic-specific committees, who are tasked 
with reviewing the evidence base and existing measures to identify 
opportunities for using performance measurement to improve health and 
healthcare, and to reduce disparities, costs, and measurement burden. 
In December 2013, four of the five committees submitted draft 
conceptual frameworks and environmental scans of measures to HHS, which 
are described in more detail below.

[[Page 41574]]

Adult Immunization

    The Adult Immunization committee--with the help of an advisory 
group--outlined a draft framework that builds on concepts identified by 
the Quality and Performance Measures Workgroup of the HHS Interagency 
Adult Immunization Task Force. The draft framework also seeks to 
illustrate measure gaps in specific age bands and special populations 
including young adults, pregnant women, the elderly and adults overall. 
During an October 2013 meeting, the committee made several suggestions 
for improving the framework, including the need to:
     Clarify all terms and include definitions;
     Include all special populations from the immunization 
schedule;
     Separate immunization of healthcare personnel from other 
populations;
     Include measures for Immunization Information systems 
(IIS); and
     Include measures from the Meaningful Use program.

The draft framework's accompanying environmental scan discovered 225 
relevant measures addressing adult immunization, many of which are 
concentrated in a few areas, such as influenza and pneumococcal 
immunization. In addition, the majority of vaccine measures are process 
measures (69 percent), and outcome measures are primarily only at the 
population, not provider, level.
    The committee will meet in early 2014 to provide further input into 
the conceptual framework, and again in March 2014 to develop 
recommendations on measures and measure concepts that can be further 
developed as performance measures. The committee will also be tasked 
with making recommendations that foster harmonization and alignment of 
measures.

Care Coordination

    The Care Coordination committee developed a draft conceptual 
framework that builds on work from the Agency for Healthcare Research 
and Quality's Care Coordination Measures Atlas and their Clinical-
Community Relationship Measurement concept. The draft framework's 
accompanying environmental scan identified a total of 363 measures 
related to care coordination. While the scan produced a significant 
number of measures relating to the general concept of care 
coordination, very few describe ongoing interactions between primary 
care and community-based service providers to support improved health 
and quality of life. In general, currently available measures are 
either too narrowly or too broadly designed to be actionable by 
providers of primary care. Further, no available measures directly 
apply to providers of community services.
    This committee will meet in early 2014 to further refine the 
conceptual framework, and consider options for addressing measure gaps 
that draw on promising practices for care coordination with respect to 
the following questions:
     What are the most important care coordination measurement 
domains at the interest of primary care and community services?
     How much reliance is appropriate to place on care 
recipients and caregivers to serve as the coordinators between the 
medical and non-medical systems?
     Should shared decision-making be added as a domain in the 
care coordination framework and if so how does this relate to care 
planning?
     What are direct outcomes of care coordination (e.g., 
improved patient/family experience)?
     To what other outcomes does care coordination contribute 
(e.g., improved health status, progress toward the NQS)?

Health Workforce

    Achieving the National Quality Strategy's aims of better care, 
affordable care, and healthy people/healthy communities will require an 
adequate supply and distribution of a well-trained workforce. 
Therefore, in consultation with HHS and with input from advisory 
members, NQF developed a draft conceptual framework for measurement 
that captures elements necessary for successful and measureable 
workforce deployment. The draft framework builds on existing resources 
and frameworks, including NQF's Multiple Chronic Condition Framework, 
the Agency for Healthcare Research and Quality's (AHRQ) Clinical-
Community Relationships Measures Atlas and Care Coordination Measures 
Atlas, and the Institute of Medicine's (IOM) Health Professions 
Education: A Bridge to Quality. It also includes definitions of key 
importance to this work, including workforce, primary care, care 
coordination, and health. Furthermore, the framework seeks to encompass 
measurement across the life-span and for measurement opportunities 
beyond clinical settings.
    More than 200 measures were identified in the environmental scan as 
potential health workforce measures. Large sets of measures were found 
related to training and development, mostly related to professional 
educational programs and the number of graduates in specific health 
professions. Although many measures of patient and family experience of 
care related to workforce performance were identified, few measures 
capturing workforce experience were found. Workforce capacity and 
productivity measures proved to have a substantial presence, especially 
those related to geographical distribution and skill mix. A significant 
number of measures related to infrastructure were also identified, a 
majority of which were specifically focused on the ability to use HIT 
to provide care and patient access to primary prevention services.
    The health workforce committee will meet again in early 2014 to 
further refine the framework, consider high-priority opportunities for 
measure development and endorsement, and discuss promising measures, 
measure concepts and remaining gaps in critical measurement areas.

Person-Centered Care and Outcomes

    The Person-Centered Care and Outcomes committee also outlined a 
draft conceptual framework that offered a definition for and core 
concepts of person- and family-centered care that was influenced by 
previous work from the Institute for Patient- and Family-Centered Care 
and the Institute of Medicine:

Patient- and family-centered care is an approach to the planning, 
delivery, and evaluation of health care that is grounded in mutually 
beneficial partnerships among health care providers, patients, and 
families. The core concepts include respect and dignity, information 
sharing, participation, and collaboration.

The project's environmental scan identified 803 measures as broadly 
relevant, touching on topics such as patient experience with care, 
health-related quality of life, and symptom and symptom burden. The 
majority of measures fell under the domain of patient experience, 
covering a variety of care settings and types of care, as well as 
disease-specific populations. Many of the health related quality of 
life and symptom and symptom burden measures identified may be better 
classified as indicators of treatment effectiveness, which the 
committee will consider when they meet again in early 2014. The 
committee will also develop a vision of the ideal state or ``North 
Star'' of person-centered care, and identify how best to measure 
performance and progress in the delivery of person-centered care 
against this vision.

[[Page 41575]]

Alzheimer's Disease and Related Dementias

    HHS requested that the Alzheimer's disease and Related Dementias 
committee begin work on a draft conceptual framework and environmental 
scan after the previously mentioned committees--especially the care 
coordination and person-centered care and outcomes committees--compiled 
their findings. This request was made so that the Alzheimer's disease 
and Related Dementias committee could incorporate the findings from 
these two committees into their own work product. As a result, a draft 
conceptual framework and environmental scan will be completed in 
February 2014.

Identifying Other Measure Gaps

    NQF identified additional high-priority measure gaps through other 
work by MAP and NQF's endorsement and maintenance work. More 
specifically, the Dual Eligible Beneficiaries Workgroup providing 
greater specificity to measure developers and funders, and identified 
the following list of gaps:
     Goal-directed, person-centered care planning and 
implementation
     Shared decision-making
     Systems to coordinate healthcare with non-medical 
community resources and service providers
     Beneficiary sense of control/autonomy/self-determination
     Psychosocial needs
     Community integration/inclusion and participation
     Optimal functioning (e.g., improving when possible, 
maintaining, managing decline)

Importantly, this list reflects the MAP's vision for high-quality care 
for Medicare-Medicaid enrollees, which has been articulated in previous 
reports. Identification of these gaps supports a philosophy about 
health that broadly accounts for individuals' health outcomes, personal 
wellness, social determinants (e.g., housing, transportation, access to 
community resources), and desire for a more cohesive system of care 
delivery. Many gaps are long-standing, which underscores both the 
importance of non-medical supports and services in contributing to 
improved healthcare quality and the difficulty of quantifying and 
measuring these factors as indicators of performance.
    Specifically, the MAP recommends for future measure development 
continuing a focus on topics that are meaningful to consumers, such as 
individual engagement, experience, and outcomes. In addition, the MAP 
emphasizes the need for cross-cutting measures that apply to care and 
supports at all levels to promote shared accountability and 
collaboration. Measures should incorporate information from patients 
receiving services, providers, health plans, other accountable 
entities, and/or states. Several measure gap areas are prioritized here 
for the first time, including psychosocial needs, shared decision-
making, and community integration/inclusion and participation. The MAP 
will continue to communicate with measure developers and other 
stakeholders positioned to help fill measurement gaps.
    Although the MAP's work to-date on measure gaps--including the pre-
rulemaking efforts and input from specific workgroups--is starting to 
bear fruit, persistent gaps across sectors, such as care coordination 
and patient experience, continue to frustrate measurement efforts. Many 
factors contribute to influence these gaps which are outside of the 
MAP's control, such as the lack of an information technology structure 
to facilitate care coordination, and challenges associated with 
collecting patient experience data at the clinician level. However, the 
MAP, in coordination with NQF's larger initiatives, will continue to 
try and influence ongoing progress in filling measure gaps through its 
specific recommendations and by enhanced collaboration with other 
stakeholders.
    Gaps are also routinely identified as an outgrowth of NQF's annual 
endorsement and maintenance process. Specific measure gaps identified 
through 2013 work, by topic area, include:

Infectious Disease

     Measures addressing patient outcomes;
     Additional measures dealing with HIV/AIDS, including 
testing for individuals ages 13-64; colposcopy screening for HIV-
positive women who have abnormal Pap test results; resistance testing 
for persons newly enrolled in HIV care with viral loads greater than 
1000; and HIV testing for pregnant women on initial visits;
     Process and outcome measures that evaluate improvements in 
device-associated infections in hospital settings, particularly for 
catheter- associated urinary tract infections;
     Outcome measures that include follow-up for screening 
tests; and
     Screening for additional sexually transmitted infections, 
including human papillomavirus (HPV).

 Neurology

     Palliative and end-of-life care measures for stroke 
patients;
     Functional status outcome measures, especially related to 
stroke severity;
     Measures that focus on patients with health disparities 
and disabilities;
     Pre-hospital care and emergency response measures; and
     Post-acute care and rehabilitation care measures.

Patient Safety

     Wound care measures, such as vascular screening for 
patients with leg ulcers, or adequate support surface for patients with 
stage III-IV pressure ulcers;
     Obstetric measures, such as induction and augmentation of 
labor, or outcomes of neonatal birth injury;
     Infection measures, such as vascular catheter infections;
     Equipment-related injury measures, such as monitoring of 
product-related events;
     Information technology measures, such as EHR programming 
related events;
     Physical mobility expectation measures for hospitalized 
adults;
     Measures that extend to settings outside of the hospital, 
such as nursing homes;
     Measures addressing falls across the care continuum and 
take into account patient assessments, plans of care, interventions, 
and outcomes; and
     Measures focused on complications linked to surgical site 
infections, including cesarean sections and outcomes.

Pulmonary/Critical Care

     Measures focused on in-hospital, severity adjusted, high 
mortality conditions such as 30-day mortality rates, readmissions, 
sepsis and acute respiratory distress syndrome (ARDS);
     Measures for earlier identification of sepsis at the 
compensated stage before it becomes decompensated septic shock and 
appropriate resuscitative measures;
     Measures of efficiency and overutilization;
     Measures that focus on palliative care for patients with 
end-stage pulmonary conditions;
     Better measures of comprehensive asthma education; e.g., 
instruction related to the appropriate application of handheld inhalers 
prior to discharge and demonstration of use;
     Measures of unplanned pediatric extubations;
     Measures for effectiveness and outcomes of post-acute care 
for COPD patients;

[[Page 41576]]

     Measures of functional status;
     Measures for quality of spirometries in relation to 
meeting the American Thoracic Society (ATS) standards for pediatric and 
adult patients; and
     More outpatient composite measures targeted for consumer 
use.

VI. Conclusion

    NQF has evolved in the dozen plus years it has been in existence 
and since it endorsed its first performance measures more than a decade 
ago. While its focus on improving quality, enhancing safety, and 
reducing costs by endorsing performance measures has remained a 
constant, NQF recognizes the importance of getting the various 
stakeholder groups to align with respect to their use of performance 
measures and related improvement efforts. Experience has made it clear 
that sector-by-sector approaches to enhancing healthcare performance 
are ineffective in our decentralized and complex healthcare system. 
They waste precious healthcare resources introduce wasteful redundancy 
and reporting burden and may even do harm.
    With funding from HHS, NQF tackled several critical issues 
affecting healthcare quality and safety in 2013 that helped advance the 
aims and priorities of the National Quality Strategy. New projects 
explored how to improve population health within communities; how 
consumers can leverage quality information to make informed healthcare 
coverage decisions; and how to dramatically improve patient safety in 
high-priority areas.
    In addition, NQF laid the foundation for the next generation of 
measures by providing guidance on composite measurement; patient-
reported outcome measures; electronic, or eMeasures; and measures that 
evaluate complex but important areas such as resource use and 
population health.
    Finally, the NQF-convened MAP focused on an array of projects, 
including recommending measures for federal public reporting and 
payment programs, developing ``families of measures'' (groups of 
measures selected to work together across settings of care in pursuit 
of specific healthcare improvement goals) for high-priority areas, and 
providing input on measures for vulnerable populations, including 
Medicare-Medicaid enrollees and adults enrolled in Medicaid.
    NQF will build on this work in the year ahead to help build a 
measure portfolio that drives the healthcare system to both delivering 
higher value healthcare at lower cost while incorporating the needs and 
preferences of patients, payers, and purchasers and ultimately 
improving patient and community health.

Appendix A: 2013 Activities Performed Under Contract With HHS

----------------------------------------------------------------------------------------------------------------
                                                                 Status (as of 12/31/  Notes/scheduled or actual
            Description                       Output                    2013)               completion date
----------------------------------------------------------------------------------------------------------------
1. Recommendations on the National Quality Strategy and Priorities
----------------------------------------------------------------------------------------------------------------
Multi-stakeholder input on a        A common framework that     In progress..........
 National Priority: Improving        offers guidance on
 Population Health by Working with   strategies for improving
 Communities.                        population health within
                                     communities.
Multi-stakeholder input into the    Review and input into core  In progress..........
 Quality Rating System.              measures and organization
                                     of information for the
                                     Health Insurance Exchange
                                     Quality Rating System.
Multi-stakeholder Action Pathway    Quarterly reports and       In progress..........
 Model in Support of the             meetings detailing
 Partnership for Patients (PfP)      progress of three action
 Initiative.                         teams addressing
                                     maternity care,
                                     readmissions, and patient
                                     and family engagement.
----------------------------------------------------------------------------------------------------------------
2. Quality and Efficiency Measurement Initiatives
----------------------------------------------------------------------------------------------------------------
Pulmonary/critical care measures    Project to endorse new      Completed............  36 total measures
 and maintenance review.             pulmonary/critical-care                            endorsed by March 2013.
                                     measures, and conduct
                                     maintenance on existing
                                     NQF-endorsed measures.
Patient safety measures...........  Set of endorsed measures    Completed............  Phase 2 endorsed two
                                     for patient safety.                                measures in January
                                                                                        2013.
Behavioral health measures and      Set of endorsed measures    Phase 2 in progress..  Phase 2 is considering 24
 maintenance review.                 for behavioral health.                             measures for endorsement
                                                                                        in January 2014.
Neurology measures and maintenance  Set of endorsed measures    Completed............  Phase 2 endorsed five
 review.                             for neurology.                                     measures addressing
                                                                                        stroke treatment in
                                                                                        March 2013.
Infectious disease measures and     Set of endorsed infectious  Completed............  16 measures endorsed by
 maintenance review.                 disease measures.                                  March 2013.
Review of time-limited endorsement  Fully endorsed measures     Completed............  Four measures were fully
 measures.                           after completed testing                            endorsed in April 2013.
                                     results are reviewed.
Measure maintenance...............  Review of endorsed          Ongoing..............
                                     measures every three
                                     years against newly
                                     submitted measures.
eMeasure feasibility testing......  Review the current state    Completed............  Final report completed
                                     of feasibility assessment                          April 2013.
                                     for eMeasures and
                                     identify a set of
                                     principles,
                                     recommendations, and
                                     criteria for adequate
                                     feasibility assessment.

[[Page 41577]]

 
Composite evaluation guidance.....  Reassess NQF's existing     Completed............  Final report completed
                                     guidance for evaluating                            April 2013.
                                     composites, with
                                     particular consideration
                                     of recent changes in
                                     composite measure
                                     development and related
                                     methodology.
Readmissions and all-cause          Set of endorsed measures    In progress..........
 admissions and readmissions         for admissions and
 measures and maintenance review.    readmissions.
Cost and resource use measures....  Set of endorsed measures    In progress..........  Phase 1 endorsed 1 new
                                     for cost and resource use.                         measure in December
                                                                                        2013.
Cardiovascular measures and         Set of endorsed measures    In progress..........
 maintenance review.                 for cardiovascular
                                     conditions.
Behavioral health.................  Set of endorsed measures    In progress..........
                                     for behavioral health.
Endocrine measures and maintenance  Set of endorsed measures    In progress..........
 review.                             for endocrine conditions.
Health and well-being measures and  Set of endorsed measures    In progress..........
 maintenance review.                 for health and well-being.
Patient safety measures and         Set of endorsed measures    In progress..........
 maintenance review.                 for patient safety.
Care coordination measures and      Set of endorsed measures    In progress..........
 maintenance review.                 for care coordination.
Musculoskeletal measures and        Set of endorsed measures    In progress..........
 maintenance review.                 for musculoskeletal
                                     conditions.
Person- and family-centered care    Set of endorsed measures    In progress..........
 measures and maintenance review.    for person- and family-
                                     centered care.
Surgery measures and maintenance    Set of endorsed measures    In progress..........
 review.                             for surgery.
Episode grouper criteria..........  Report examining necessary  In progress..........
                                     submission elements for
                                     evaluation, as well as
                                     best practices for
                                     episode grouper
                                     construction.
Common formats for patient safety   A set of comments and       In progress..........
 data.                               advice for further
                                     refining additional
                                     modules for the Common
                                     Formats, an AHRQ-based
                                     initiative that helps
                                     standardize electronic
                                     reporting of patient
                                     safety event data.
Transition of the Quality Data      Successfully transition     Completed............  Federally-funded research
 Model (QDM).                        the QDM maintenance to                             development center now
                                     MITRE Corporation.                                 fully responsible for
                                                                                        the QDM.
----------------------------------------------------------------------------------------------------------------
3. Stakeholder Recommendations on Quality and Efficiency Measures and National Priorities
----------------------------------------------------------------------------------------------------------------
Recommendations for measures to be  Measure Applications        Completed............  Completed February 2013.
 implemented through the federal     Partnership Pre-
 rulemaking process for public       Rulemaking Report: Input
 reporting and payment.              on Measures Under
                                     Consideration by HHS for
                                     2013 Rulemaking.
Recommendations for measures to be  Measure Applications        In progress..........
 implemented through the federal     Partnership Pre-
 rulemaking process for public       Rulemaking Report: Input
 reporting and payment.              on Measures Under
                                     Consideration by HHS for
                                     2014 Rulemaking.
Synthesizing Evidence and           New families of measures    In progress..........
 Convening Key Stakeholders to       covering affordability,
 Make Recommendations on Families    population health, and
 of Measures and Risk Adjustment.    person- and family-
                                     centered care. Also a
                                     final set of
                                     recommendations focused
                                     on risk adjustment for
                                     resource use performance
                                     measures.
Identification of Quality Measures  Annual input on the         In progress..........
 for Dual-Eligible Medicare-         Initial Core Set of
 Medicaid Enrollees and Adults       Health Care Quality
 Enrolled in Medicaid.               Measures for Adults
                                     Enrolled in Medicaid, and
                                     additional refinements to
                                     previously published
                                     Families of Measures.
----------------------------------------------------------------------------------------------------------------
4. Gaps in Endorsed Quality and Efficiency Measures
----------------------------------------------------------------------------------------------------------------
Gaps report.......................  A report identifying gaps   Completed............  Final report completed
                                     in endorsed quality                                February 2013.
                                     measures, including
                                     measures within the
                                     National Quality Strategy
                                     priority areas.
----------------------------------------------------------------------------------------------------------------
5. Gaps in Evidence and Targeted Research Needs
----------------------------------------------------------------------------------------------------------------

[[Page 41578]]

 
Priority Setting for Health Care    Recommended sets of         In progress..........
 Performance Measurement:            priorities for
 Addressing Performance Measure      performance improvement
 Gaps in Priority Areas.             in five topic areas:
                                     Adult immunizations;
                                     Alzheimer's disease and
                                     related dementias; care
                                     coordination; health
                                     workforce; and person-
                                     centered care and
                                     outcomes.
Gaps report.......................  A report identifying gaps   Completed............  Final report completed
                                     in endorsed quality                                March 2013.
                                     measures, including
                                     measures within the
                                     National Quality Strategy
                                     priority areas.
----------------------------------------------------------------------------------------------------------------

Appendix B: Measure Evaluation Criteria

    Measures are evaluated for their suitability based on 
standardized criteria in the following order:

1. Importance to Measure and Report:  http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#importance
2. Scientific Acceptability of Measure Properties: http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#scientific
3. Feasibility: http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#feasibility
4. Usability and Use: http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#usability
5. Related and Competing Measures: http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#comparison

    More information is available on the NQF Web site at: http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx#1_2.

Appendix C: Federal Public Reporting and Performance-Based Payment 
Programs Considered by MAP

End Stage Renal Disease Quality Improvement Program
Home Health Quality Reporting
Hospice Quality Reporting
Inpatient Rehabilitation Facility Quality Reporting
Long-Term Care Hospital Quality Reporting
Ambulatory Surgical Center Quality Reporting
Hospital Acquired Condition Payment Reduction (ACA 3008)
Hospital Inpatient Quality Reporting
Hospital Outpatient Quality Reporting
Hospital Readmission Reduction Program
Hospital Value-Based Purchasing
Inpatient Psychiatric Facility Quality Reporting
Prospective Payment System (PPS) Exempt Cancer Hospital Quality 
Reporting
Medicare and Medicaid EHR Incentive Program for Hospitals and CAHs
Medicare and Medicaid EHR Incentive Program for Eligible 
Professionals
Medicare Shared Savings Program
Medicare Physician Quality Reporting System (PQRS)
Physician Feedback/Quality and Resource Utilization Reports
Physician Value Based Payment Modifier
Physician Compare

Appendix D: MAP Structure, Members, and Criteria for Service

    The MAP operates through a two-tiered structure. Guided by the 
priorities and goals of HHS's National Quality Strategy, the MAP 
Coordinating Committee provides direction and direct input to HHS. 
MAP's workgroups advise the Coordinating Committee on measures 
needed for specific care settings, care providers, and patient 
populations. Time-limited task forces charged with developing 
``families of measures''--related measures that cross settings and 
populations--provide further information to the MAP Coordinating 
Committee and workgroups. Each multi-stakeholder group includes 
individuals with content expertise and organizations particularly 
affected by the work.
    The MAP's members are selected based on NQF Board-adopted 
selection criteria, through an annual nominations process and an 
open public commenting period. Balance among stakeholder groups is 
paramount. Due to the complexity of MAP's tasks, individual subject 
matter experts are included in the groups. Federal government ex 
officio members are non-voting because federal officials cannot 
advise themselves. MAP members serve staggered three-year terms.

MAP Members

 Coordinating Committee: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=49410
 Clinician Workgroup: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=56141
 Dual Eligible Beneficiaries Workgroup: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=56142
 Hospital Workgroup: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=56143
 Post-Acute Care/Long-Term Care Workgroup: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=56140

    \1\ Throughout this report, the relevant statutory language 
appears in italicized text.
    \2\ http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf.
    \3\ http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf.
    \4\ http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=74553.
    \5\ http://partnershipforpatients.cms.gov/.
    \6\ NQF steering committees are comparable to the expert 
advisory committees typically convened by federal agencies.
    \7\ Reserve status measures are reliable, valid measures that 
have overall high levels of performance with little variability and 
retain endorsement, so that performance may be monitored in the 
future to ensure performance does not decline.
    \8\ American Lung Association. Available at http://www.lungusa.org/assets/documents/publications/lung-disease-data/solddc_2010.pdf. Last accessed October 2011.
    \9\ Centers for Disease Control. Available at http://www.cdc.gov/aging/aginginfo/alzheimers.htm. Last accessed February 
2012.
    \10\ American Health Assistance Foundation. Available at http://www.ahaf.org/alzheimers/about/understanding/facts.html. Last 
accessed February 2012.
    \11\ Centers for Disease Control. Available at http://www.cdc.gov/aging/aginginfo/alzheimers.htm. Last accessed February 
2012.
    \12\ Centers for Disease Control. Available at www.cdc.gov/epilepsy/basics/fast_facts.htm. Last accessed February 2012.
    \13\ Parkinson's Disease Foundation. Available at www.pdf.org/en/parkinson_statistics. Last accessed February 2012.
    \14\ Christensen KL, Holman RC, Steiner CA, et al. Infectious 
disease hospitalizations in the United States. Clin Infect Dis, 
2009;49(7):1025-1035.
    \15\ Scott RD, The Direct Medical Costs of Healthcare-Associated 
Infections in U.S. Hospitals and the Benefits of Prevention, 
Division of Healthcare Quality Promotion, National Center for 
Preparedness, Detection, and Control of Infectious Diseases; 
Coordinating Center for Infectious Diseases, Centers for Disease 
Control and Prevention; March 2009.
    \16\ http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=73046.
    \17\  http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=73039.
    \18\  http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=73046.
    \19\  http://www.qualityforum.org/Qps/QpsTool.aspx.
    \20\  http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72738.
    \21\  http://www.qualityforum.org/Publications/2013/02/MAP_Pre-
Rulemaking_Report__-February_2013.aspx.

[[Page 41579]]

    \22\  http://www.qualityforum.org/Publications/2013/02/MAP_Pre-
Rulemaking_Report__-February_2013.aspx.
    \23\  http://www.qualityforum.org/Publications/2013/03/2012_NQF_Measure_Gap_Analysis.aspx.
    \24\ e.g., Hospital Consumer Assessment of Healthcare Providers 
and Systems [HCAHPS] being tested only in the hospital inpatient 
setting, creating a gap in patient experience measurement in the 
hospital outpatient, ambulatory surgical center, and long-term care 
hospital settings.

III. Secretarial Comments on the 2014 Annual Report to Congress and the 
Secretary

    This 2014 Annual Report to Congress and the Secretary describes 
NQF's work in 2013 to fulfill the requirements specified in section 
1890 of the Social Security Act. Of particular interest to the 
Department, in 2013, NQF continued work initiated in 2010 to develop 
recommendations on the National Quality Strategy by convening 
diverse stakeholder groups to reach consensus on quality measurement 
priorities. NQF also began work in several priority areas that the 
National Quality Strategy addresses, such as improving population 
health within communities, improving patient safety in high-priority 
areas, and helping consumers leverage quality information to make 
informed healthcare coverage decisions--a critically important area 
as more people choose the health care coverage that is best for them 
through the health insurance marketplaces created by the Affordable 
Care Act.
    We are also pleased that during the year, NQF furthered its work 
on performance measures by adding 27 measures to its portfolio. We 
note that although the number of measures endorsed in 2013 is 
significantly lower than in the preceding year, the meetings that 
were convened in 2013 to endorse measures took place as the initial 
four-year contract was ending. Under the new contract, NQF began to 
develop new measures candidates, but those did not reach the stage 
of endorsement review by the end of the year.
    Moreover, in 2013, the Measure Applications Partnership (MAP), a 
public-private partnership convened by NQF: (1) Recommended measures 
for federal public reporting and payment programs; (2) developed 
``families of measures'' for high-priority areas; and (3) provided 
input on measures for vulnerable populations, including Medicare-
Medicaid enrollees and adults enrolled in Medicaid.
    NQF also continued to address the need to fill measurement gaps 
in priority areas. Under the second contract, NQF began working with 
key stakeholders to make recommendations for performance measurement 
development in five priority topic areas: (1) Adult immunization; 
(2) Alzheimer's disease and related dementias; (3) care 
coordination; (4) health workforce; and (5) person-centered care and 
outcomes.
    These and the other activities described in the 2014 Annual 
Report to Congress and the Secretary, published above, reflect the 
wide scope of work required for comprehensive, methodologically 
sound measurement of health care quality and continued improvement 
of health care in the United States. HHS thanks NQF for its 
insightful and informative work conducted in 2013.

IV. Future Steps

    As previously noted, the work reflected in the 2014 Annual 
Report to Congress and the Secretary was produced under both HHS' 
initial four-year contract with the NQF which expired in July, 2013 
and a subsequent, four-year contract. In 2014 and beyond, HHS will 
continue to work with the consensus-based entity and all 
stakeholders on ongoing measure endorsement and maintenance to 
continuously improve the set of measures available for widespread 
application. HHS will also work with NQF on more targeted and 
strategic issues such as measures regarding the quality of home and 
community-based care for people with disabilities, the use of 
information technology in quality measurement, and improving 
population health. All of these initiatives will help to fulfill the 
triple aims of the National Quality Strategy: Better health care, 
healthier people and communities, and more affordable care for all 
Americans.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 35).

    Dated: July 7, 2014.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.

[FR Doc. 2014-16391 Filed 7-15-14; 8:45 a.m.]
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