[Federal Register Volume 81, Number 171 (Friday, September 2, 2016)]
[Notices]
[Pages 60996-61029]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-20908]



[[Page 60995]]

Vol. 81

Friday,

No. 171

September 2, 2016

Part IV





Department of Health and Human Services





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Secretarial Review and Publication of the National Quality Forum Annual 
Report to Congress and the Secretary Submitted by the Consensus-Based 
Entity Regarding Performance Measurement; Notice

  Federal Register / Vol. 81 , No. 171 / Friday, September 2, 2016 / 
Notices  

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


Secretarial Review and Publication of the National Quality Forum 
Annual Report to Congress and the Secretary Submitted by the 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 2016 
National Quality Forum Annual Report to Congress and the Secretary 
submitted by the consensus-based entity (CBE) under a contract with the 
Secretary as mandated by section 1890(b)(5) of the Social Security Act, 
established by section 183 of the Medicare Improvements for Patients 
and Providers Act of 2008 (MIPPA) and amended by section 3014 of the 
Patient Protection and 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 
the statutory requirements.

FOR FURTHER INFORMATION CONTACT: Sophia Chan (410) 786-5050.
    The order in which information is presented in this notice is as 
follows:

I. Background
II. The 2016 Annual Report to Congress and the Secretary: ``NQF 
Report on 2015 Activities to Congress and the Secretary of the 
Department of Health and Human Services''
III. Secretarial Comments on the 2016 Annual Report to Congress and 
the Secretary
IV. Collection of Information Requirements

I. Background

    The Patient Protection and Affordable Care Act of 2010 (ACA) 
provides strategies and tools to more fully achieve ``Quality, 
Affordable Health Care For All Americans''--Title I of ACA. In the six 
years since its passage, 20 million people have gained access to health 
care, (See ASPE. ``HEALTH INSURANCE COVERAGE AND THE AFFORDABLE CARE 
ACT, 2010-2016 available at: https://aspe.hhs.gov/pdf-report/health-
insurance-coverage-and-affordable-care-act-2010-2016'') and the quality 
of that care is significantly improved. Fewer Americans are losing 
their lives or falling ill due to conditions acquired in the hospital 
such as pressure ulcers, infections, falls and traumas. Hospital-
acquired conditions are estimated to have declined by 17 percent 
between 2010 and 2014. Preliminary data show that between 2010 and 
2014, there was a decrease in these conditions by more than 2.1 million 
events; and as a result, 87,000 fewer people lost their lives. See: 
``Saving Lives and Saving Money: Hospital-Acquired Conditions Update.'' 
December 2015. Agency for Healthcare Research and Quality, Rockville, 
MD. http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2014.html.
    A key ACA strategy for ``Improving The Quality and Efficiency of 
Health Care'' (Title III of ACA) is to transform the health care 
delivery system by encouraging development of new patient care models 
and linking payment to quality outcomes in the Medicare program. As 
part of this strategy, the Department of Health and Human Services 
(HHS) has established a goal of tying 30 percent of traditional or fee-
for-service Medicare payments to quality or value through alternative 
payment models by the end of 2016; and 50 percent of payments to these 
models by the end of 2018. HHS also set a goal of tying 85 percent of 
all traditional Medicare payments to quality or value by 2016 and 90 
percent by 2018 through programs such as the Hospital Value-Based 
Purchasing Program. In March 2016, HHS announced that it has reached 
the goal of tying 30 percent of traditional Medicare payments to 
alternative payment models nearly a year ahead of schedule.
    Efforts to transform the health care system to provide higher 
quality care require accurate, valid, and reliable measurement of the 
quality and efficiency of health care. Recognition of the need for such 
measurement predates ACA; MIPPA created section 1890 of the Social 
Security Act (the Act), which requires the Secretary of HHS to contract 
with a CBE to perform multiple duties to help improve performance 
measurement. Section 3014 of ACA expanded the duties of the CBE to help 
in the identification of gaps in available measures and to improve the 
selection of measures used in health care programs.
    In response to MIPPA, in January of 2009, a competitive contract 
was awarded by HHS to the National Quality Forum (NQF) to fulfill 
requirements of section 1890 of the Act. A second, multi-year contract 
was awarded again to NQF after an open competition in 2012. This 
contract now includes the following duties created by MIPPA and ACA and 
contained in section 1890(b) of the Act:
    Priority Setting Process: Formulation of a National Strategy and 
Priorities for Health Care Performance Measurement. The CBE is to 
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. In 
doing so, the CBE is to give priority to measures that: (a) Address the 
health care provided to patients with prevalent, high-cost chronic 
diseases; (b) have the greatest potential for improving quality, 
efficiency and patient-centered health care; and c) may be implemented 
rapidly due to existing evidence, standards of care or other reasons. 
Additionally, the CBE must take into account measures that: (a) May 
assist consumers and patients in making informed health care decisions; 
(b) address health disparities across groups and areas; and (c) address 
the continuum of care across multiple providers, practitioners and 
settings.
    Endorsement of Measures: The CBE is to provide for the endorsement 
of standardized health care performance measures. This process must 
consider whether measures are evidence-based, reliable, valid, 
verifiable, relevant to enhanced health outcomes, actionable at the 
caregiver level, feasible to collect and report, responsive to 
variations in patient characteristics such as health status, language 
capabilities, race or ethnicity, and income level and are consistent 
across types of health care providers, including hospitals and 
physicians.
    Maintenance of CBE Endorsed Measures. The CBE is required to 
establish and implement a process to ensure that endorsed measures are 
updated (or retired if obsolete) as new evidence is developed.
    Review and Endorsement of an Episode Grouper Under the Physician 
Feedback Program. ``Episode-based'' performance measurement is an 
approach to better understanding the utilization and costs associated 
with a certain condition by grouping together all the care related to 
that condition. ``Episode groupers'' are software tools that combine 
data to assess such condition-specific utilization and costs over a 
defined period of time. The CBE is required to provide for the review, 
and as appropriate, endorsement of an episode grouper as developed by 
the Secretary.
    Convening Multi-Stakeholder Groups. The CBE must 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

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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 for improvement in population 
health and 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 provide input on 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.
    Transmission of Multi-Stakeholder Input. Not later than February 1 
of each year, the CBE is to transmit to the Secretary the input of 
multi-stakeholder groups.
    Annual Report to Congress and the Secretary. Not later than March 1 
of each year, the CBE is required to submit to Congress and the 
Secretary of HHS an annual report. The report is to describe:

    (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 the CBE's duties required under its 
contract with HHS;
    (iv) gaps in endorsed quality and efficiency measures, including 
measures that are within priority areas identified by the Secretary 
under the national 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 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.

    The statutory requirements for the CBE to annually report to 
Congress and the Secretary of HHS also specify that the Secretary of 
HHS must review and publish the CBE's annual report in the Federal 
Register, together with any comments of the Secretary on the report, 
not later than six months after receiving it.
    This Federal Register notice complies with the statutory 
requirement for Secretarial review and publication of the CBE's annual 
report. NQF submitted a report on its 2015 activities to the Secretary 
on March 1, 2016. This 2016 Annual Report to Congress and the Secretary 
of the Department of Health and Human Services is presented below in 
Section II. Comments of the Secretary on this report are presented 
below in section III.

II. The 2016 Annual Report to Congress and the Secretary: ``NQF Report 
of 2015 Activities to Congress and the Secretary of the Department of 
Health and Human Services''

I. Executive Summary

    Over the last eight years, Congress has passed two statutes with 
several extensions that call upon the Department of Health and Human 
Services (HHS) to work with a consensus-based entity (the ``entity'') 
to facilitate multistakeholder input into: (1) Setting national 
priorities for healthcare performance measurement, and (2) endorsement 
and maintenance of measures. The first of these statutes is the 2008 
Medicare Improvements for Patients and Providers Act (MIPPA) (Pub. L. 
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 American Taxpayer Relief Act of 2012 (PL 
112-240) extended funding under the MIPPA statute to the consensus-
based entity through fiscal year 2013. The Protecting Access to 
Medicare Act of 2014 (PAMA) (Pub. L. 113-93) extended funding under the 
MIPPA and ACA statutes to the consensus-based entity through March 31, 
2015. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) 
(Pub. L. 114-10) extended funding for fiscal years 2015 through 2017. 
HHS has awarded the consensus-based entity contract under these 
statutes to the National Quality Forum (NQF).
    Section 1890(b)(5) of the Social Security Act specifically charges 
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)--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 an integrated national strategy and 
priorities for health care performance measurement in all applicable 
settings; (3) NQF's performance of the duties required under its 
contract with HHS; (4) gaps in endorsed quality and efficiency 
measures, including measures that are within priority areas identified 
by the Secretary under HHS' national strategy, and where quality and 
efficiency measures are unavailable or inadequate to identify or 
address such gaps; (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) matters related to convening multistakeholder groups to 
provide input on: (a) The selection of certain quality and efficiency 
measures, and (b) national priorities for improvement in population 
health and in the delivery of healthcare services for consideration 
under the National Quality Strategy.\i\
    This seventh annual report highlights NQF's work related to these 
laws and conducted between January 1 and December 31, 2015, under 
contract with the HHS. The deliverables produced under contract in 2015 
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 Act mandates that the consensus-based 
entity (entity) 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 health care 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

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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, or other reasons. 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).\ii\ 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 endorsing measures linked 
to the NQS priorities and by convening diverse stakeholder groups to 
reach consensus on key strategies for performance measurement. In 2015, 
NQF began or completed work in several emerging areas of importance 
that address the NQS, such as how to improve population health within 
communities, the need to address gaps in quality measurement in home 
and community-based services, and exploring quality reporting 
improvements in rural communities.
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 to collect 
and report, responsive to variations in patient characteristics, and 
consistent across health care providers. In addition, the entity must 
maintain endorsed measures, including updating endorsed measures or 
retiring obsolete measures as new evidence is developed.
    Since its inception in 1999, NQF has developed a measure portfolio 
that currently contains approximately 600 measures, subsets of which 
are used in a variety of settings. About 300 NQF-endorsed measures are 
used in more than 20 federal public reporting and pay-for-performance 
programs; these measures used in the federal programs along with other 
endorsed measures are also used in private-sector and state programs.
    In building upon NQF's endorsement and maintenance work, HHS 
charged NQF with two new tasks in the areas of variation of measures 
and attribution. These two new tasks that aim to improve maintenance 
and usability of endorsed measures relate to how a measure works both 
in the field on an operational basis and in payment linked to measure 
performance.
    Health Information Technology (HIT) continues to evolve and drive 
change in healthcare for both providers and patients. As this field 
grows rapidly, it is important to recognize and understand the 
potential effects that HIT will have on performance measures. While HIT 
presents many new opportunities to improve patient care and safety, it 
can also create new hazards and pose additional challenges, 
specifically regarding establishing harmonized and consistent value 
sets--potentially altering measures and leaving validity and 
reliability at question. NQF embarked on two new task orders 
specifically addressing patient safety in HIT and value set 
harmonization.
    In 2015, NQF endorsed 161 measures and removed 42 measures from its 
portfolio across 14 HHS-funded projects. These measure endorsement and 
maintenance projects help ensure that the measure portfolio contains 
``best-in-class'' measures across a variety of clinical and cross-
cutting topic areas. 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 because they are best-in-class. 
Working with expert multistakeholder committees,\iii\ NQF undertakes 
actions to keep its endorsed measure portfolio relevant.
    In 2015, NQF endorsed measures in order to:
    Drive the healthcare system to be more responsive to patient/family 
needs. This effort included continued work in Person- and Family-
Centered Care and Care Coordination, and Palliative and End-of-Life 
Care endorsement projects, which included endorsing patient-reported 
outcome measures and patient experience surveys.
    Improve care for highly prevalent conditions. NQF's work included 
Cardiovascular, Renal, Endocrine, Behavioral Health, Musculoskeletal, 
Eye Care and Ear, Nose and Throat Conditions, Pulmonary/Critical Care, 
Neurology, Perinatal, and Cancer endorsement projects.
    Emphasize cross-cutting areas to foster better care and 
coordination. This effort included Behavioral Health, Patient Safety, 
Cost and Resource Use, and All-Cause Admissions and Readmissions 
endorsement projects.
    During 2015, NQF also removed 42 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 that they no longer wished 
to maintain; a better, substitute measure was submitted; or measures 
``topped out,'' with providers consistently performing at the highest 
level. Continuously culling the portfolio through these means and 
through the measure maintenance process ensures that the NQF portfolio 
is relevant to the most current practices in the field.
    In October 2015, HHS awarded NQF additional endorsement projects, 
addressing topics such as pulmonary and critical care, neurology, 
perinatal, cancer, and palliative and end-of-life care. NQF has begun 
work on these projects by issuing calls for measures to be reviewed and 
considered for endorsement.
Stakeholder Recommendations on Quality and Efficiency Measures
    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 multistakeholder 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, the 
consensus-based entity is to report the input of the multistakeholder 
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). MAP was created to provide input to HHS on the selection 
of quality and efficiency measures for more than 20 federal public 
reporting and performance-based payment programs. Launched in the 
spring of 2011, MAP is comprised of representatives from more than 90 
major

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private-sector stakeholder organizations and seven federal agencies.
    During the 2014-2015 pre-rulemaking process, MAP examined almost 
200 unique measures for consideration for use in 20 different federal 
health programs. MAP convened workgroups specified by care settings 
both in person and by webinar to evaluate the measures and make 
recommendations concerning their proposed use in various federal 
programs.
    In 2015, MAP conducted an ``off-cycle'' review to provide 
recommendations to HHS on a selection of performance measures under 
consideration to implement the Improving Medicare Post-Acute Care 
Transformation (IMPACT) Act of 2014 (Pub. L. 113-185). An off-cycle 
deliberation is one that occurs outside of the usual timing for MAP 
deliberations and in which HHS seeks input from the MAP on additional 
measures under consideration on an expedited 30-day timeline. The 
IMPACT Act requires, among other things, standardized patient 
assessment data to enable comparisons across four different post-acute 
care settings: skilled nursing facilities, inpatient rehabilitation 
facilities, long-term care hospitals, and home health agencies. In 
these deliberations, MAP highlighted the importance of integrating data 
with existing assessment instruments where possible, as well as noted 
the challenges in standardizing across the four different settings of 
care.
    Under separate funding from the CMS, MAP also convened task forces 
to address the unique needs of Medicare and Medicaid dual 
beneficiaries, as well as made recommendations on strengthening the 
Adult and Child Core Sets of Measures utilized in Medicaid and CHIP 
programs. The Adult Core Set refers to the Core Set of Health Care 
Quality Measures for Adults Enrolled in Medicaid. The Child Core Set 
refers to the Core Set of Healthcare Quality Measures for Children 
Enrolled in Medicaid and CHIP. Work on the Adult and Child core sets of 
measures utilized in the Medicaid and CHIP programs helped HHS fulfill 
requirements for Child and Adult core sets of measures required under 
the Affordable Care Act (ACA) Sec.  2701 and the Children's Health 
Insurance Program Reauthorization Act of 2009 (CHIPRA).
Cross-Cutting Challenges Facing Measurement: Gaps in Endorsed Quality 
and Efficiency Measures Across HHS Programs
    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.
    In 2015, NQF staff examined the current measure portfolio and after 
exhaustive review, identified over 250 measure gaps that have yet to be 
filled. Additionally, building upon its ongoing role in identifying 
gaps in measurement, MAP developed a scorecard approach which 
quantifies the number of MAP-recommended measures in gap areas 
organized by the priority areas of the National Quality Strategy.
    MAP also addressed the need for alignment across multiple programs 
by focusing on comparable performance across care settings, data 
sources, and measure elements to facilitate better information exchange 
that could close potential ``reporting gaps,'' areas of measurement 
lacking sufficient data, across the healthcare system.
Coordination With Measurement Initiatives Implemented by Other Payers
    Section1890(b)(5)(A)(i) of the Social Security Act mandates that 
the Annual Report to Congress and the Secretary include a description 
of the implementation of quality and efficiency measurement initiatives 
under this Act and the coordination of such initiatives with quality 
and efficiency initiatives implemented by other payers.
    This year NQF worked with other payers and entities to better 
understand the areas of alignment and socioeconomic risk adjustment of 
measures in an effort to coordinate quality measurement across the 
public and private sectors.
    The Centers for Medicare & Medicaid Services (CMS) and America's 
Health Insurance Plans (AHIP) brought together private- and public-
sector payers to work on better measure alignment in 2015. NQF provided 
technical assistance to this effort which is largely focused on 
aligning clinician level measures in ambulatory settings across CMS and 
private plans. While these collaborative efforts are not intended to 
solve all alignment challenges, they will serve as an important first 
step toward accomplishing a lofty and very necessary goal.
    Additionally, NQF commenced a two-year trial period, evaluating 
risk adjustment of measures for socioeconomic status (SES) and other 
demographic factors. This two-year trial period is a temporary policy 
change that will allow for the SES risk adjustment of performance 
measures where there is a sound conceptual and empirical basis for 
doing so. At the conclusion of this trial period, NQF will determine 
whether to make this policy change permanent.

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 (entity) 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. In making such recommendations, 
the entity shall ensure that priority is given to measures: (i) That 
address the health care provided to patients with prevalent, high-cost 
chronic diseases; (ii) with the greatest potential for improving the 
quality, efficiency, and patient-centeredness of health care; and (iii) 
that may be implemented rapidly due to existing evidence, standards of 
care, or other reasons.'' In addition, the entity is to ``take into 
account measures that: (i) May assist consumers and patients in making 
informed healthcare decisions; (ii) address health disparities across 
groups and areas; and (iii) address the continuum of care a patient 
receives, including services furnished by multiple health care 
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).\iv\ 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.
    Annually, NQF has continued to further the National Quality 
Strategy by endorsing measures linked to the NQS priorities and by 
convening diverse stakeholder groups to reach consensus on key 
strategies for performance measurement. In 2015, NQF began or

[[Page 61000]]

completed work in several emerging areas of importance that address the 
National Quality Strategy, such as population health within 
communities, measurement gap identification in home and community-based 
services, and rural health.
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's related 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 Affordable Care Act 
(ACA), the federal government has had opportunities to meaningfully 
coordinate its improvement efforts with those of local communities in 
order to better integrate and align medical care and population health. 
Such efforts can help improve the nation's overall health and 
potentially lower costs.
    In September 2014, NQF launched phase 2 of the Population Health 
Framework project, enlisting 10 diverse communities to begin an 18-
month field test of the deliverables of the first phase of this 
project. The deliverables included an evidence-based framework; key 
terms; a core set of measure domains and measures, building off of the 
CMS-developed domains and subdomains; measure gaps; data granularity 
needed to produce actionable information at the community level; and a 
list of essential `actors' who need to be engaged in community-based 
work to chart and undertake a course of action when embarking on a 
systematic effort to improve population health in their region. The 10 
field testing groups participating include:

1. Colorado Department of Health Care Policy and Financing (HCPF), 
Denver, CO
2. Community Service Council of Tulsa, Tulsa, OK
3. Designing a Strong and Healthy NY (DASH-NY), New York, NY
4. Empire Health Foundation, Spokane, WA
5. Kanawha Coalition for Community Health Improvement, Charleston, WV
6. Mercy Medical Center and Abbe Center for Community Mental Health--A 
Community Partnership with Geneva Tower, Cedar Rapids, IA
7. Michigan Health Improvement Alliance, Central Michigan
8. Oberlin Community Services and The Institute for eHealth Equity, 
Oberlin, OH
9. Trenton Health Team, Inc., Trenton, NJ
10. The University of Chicago Medicine Population Health Management 
Transformation, Chicago, IL

    During the field test, these groups are participating in a variety 
of activities including:
     Applying the ``Guide for community action'' handbook 
developed in phase 1 of this project and released in August of 2014 to 
new or existing population health improvement projects;
     Determining what works and what needs enhancement in the 
guide; and
     Offering examples and ideas for revised or new content 
based on their own experiences.
    These communities represent a range of groups, each with different 
levels of experience, varied geographic and demographic focus, and 
demonstrated involvement in or plans to establish population health-
focused programs. These groups participate through in-person Committee 
meetings and monthly conference calls.
    In July 2015, the Guide for community action, version 2.0 \v\ was 
published and serves as a handbook for individuals and practitioners 
that wish to improve health across a population, whether locally, in a 
broader region, or even nationally. The Guide is designed to support 
individuals and groups working together to successfully promote and 
improve population health over time. It contains brief summaries of 10 
useful elements that are important to consider when engaging in 
collaborative population health improvement efforts, and includes 
examples and links to practical resources. Version 2.0 incorporates the 
feedback and experiences from the 10 field testing groups mentioned 
above to make the information more relevant and actionable from the 
perspective of multisector partnerships working in the field.
Home and Community-Based Services
    Home and community-based services (HCBS) are vital to promoting 
independence and wellness for people with long-term care needs. The 
United States spends $130 billion each year on long-term services and 
support, a figure that is likely to increase dramatically as the number 
of Americans over age 65 is expected to double by the end of 2016.\vi\ 
Awarded in December 2014, this project will span two years and is 
currently underway.
    This project offers an important opportunity to address the gap in 
HCBS measures that support community living. NQF convened a 
multistakeholder Committee to accomplish the following tasks:
     Create a conceptual framework for measurement, including a 
definition for HCBS;
     Perform a synthesis of evidence and an environmental scan 
for measures and measure concepts;
     Identify gaps in HCBS measures based on the framework; and
     Make recommendations for HCBS measure development efforts.
    In August 2015, the Committee released an interim report titled 
Addressing Performance Measure Gaps in Home and Community-Based 
Services to Support Community Living: Initial Components of the 
Conceptual Framework.\vii\ This interim report detailed the Committee's 
work to develop a conceptual framework for quality measurement. The 
Committee identified characteristics of high-quality HCBS that express 
the importance of ensuring the adequacy of the HCBS workforce, 
integrating healthcare and social services, supporting the caregivers 
of individuals who use HCBS, and fostering a system that is ethical, 
accountable, and centered on the achievement of an individual's desired 
outcomes.
    This report aims to develop a shared understanding and approach to 
assessing the quality of home and community-based services. NQF 
reviewed state-level and international quality measurement activities 
in three states and three nations. The next steps of the project will 
discuss the evidentiary findings and environmental scan--also taking 
into consideration feasibility of measurement, barriers to 
implementation, and mitigation strategies for identified barriers. 
Project completion is expected in September 2016.
Rural Health
    Challenges such as geographic isolation, small practice size, 
heterogeneity in settings and patient population, and low case volumes 
make participation in performance measurement and improvement efforts 
especially challenging for many rural providers. Although some rural 
hospitals and clinicians participate in a variety of private-sector, 
state, and federal quality measurement and improvement efforts, many 
quality initiatives implemented by the Centers for Medicare & Medicaid 
Services (CMS)

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exclude rural healthcare providers from mandatory quality reporting and 
value-based payment programs. Notably, Critical Access Hospitals (CAH) 
are exempt from participating in the Hospital Inpatient Quality 
Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), and 
Hospital Value Based Purchasing (VBP) Programs. CAHs can voluntarily 
participate on the Hospital Compare Web site though they are not 
mandated to do so. Clinicians who are not paid under the Medicare 
Physician Fee Schedule, are for the most part, not included in the CMS 
clinical reporting and payment programs. This includes those who work 
in Rural Health Clinics and Community Health Centers.
    In September 2015, the NQF-convened Rural Health Committee released 
its final report,\viii\ which provided 14 recommendations to address 
the challenges of healthcare performance measurement for rural 
providers, including those discussed above. The recommendations are 
intended to help advance a thoughtful, practical, and relatively rapid 
integration of rural providers into CMS quality improvements efforts.
    The Committee's overarching recommendation is to make participation 
in CMS quality measurement and quality improvement programs mandatory 
for all rural providers but allow for a phased approach, calling for 
the inclusion of new reporting requirements over a number of years to 
allow rural providers time to adjust to new requirements and build the 
required infrastructure for their practices. Further, the Committee 
recommended that the low case volume must be addressed prior to 
mandatory participation in reporting programs. The Committee also made 
several additional stand-alone recommendations with the intention of 
easing the transition of rural providers from voluntary to mandatory 
participation in quality measurement and improvement programs. These 
recommendations were as follows:
    1. Fund development of rural-relevant measures--specifically 
patient hand-offs and transitions, access to care and timeliness of 
care, cost, population health at the geographic levels;
    2. Develop and/or modify measures to address low case volume 
explicitly considering measures that are broadly applicable across 
rural providers, measures that reflect wellness in the community, and 
measures constructed using continuous variables and ratio measures;
    3. Consider rural-relevant sociodemographic factors in risk 
adjustment (statistical methods to control or account for patient-
related factors when computing performance measure scores); and
    4. When creating and using composite measures, ensure that the 
component measures are appropriate for rural providers.

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 is to consider whether measures are 
evidence-based, reliable, valid, verifiable, relevant to enhanced 
health outcomes, actionable at the caregiver level, feasible for 
collecting and reporting, responsive to variations in patient 
characteristics, and consistent across types of health care providers. 
In addition, the entity must establish and implement a process to 
ensure that endorsed measures are updated (or retired if obsolete), as 
new evidence is developed.
    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. In addition, performance 
measures are increasingly used in federal accountability public 
reporting and pay-for-performance programs, to inform patient choice, 
to drive quality improvement, and to assess the effects of care 
delivery changes.
    Working with multistakeholder committees to build consensus, NQF 
reviews and endorses healthcare performance measures. Currently NQF has 
a portfolio of approximately 600 NQF-endorsed measures which are in 
widespread use; subsets of the portfolio apply to particular settings 
and levels of analysis. The federal government, states, and private 
sector organizations use NQF-endorsed measures to evaluate performance 
and to share information with employers, patients, and their families. 
Together, NQF measures serve to enhance healthcare value by ensuring 
that consistent, high-quality performance information and data are 
available, which allows for comparisons across providers and the 
ability to benchmark performance.
    In building upon NQF's endorsement work, HHS charged NQF with two 
new tasks related directly to the use of endorsed measures--both in the 
field and in their relation to payment. At the direction of HHS, NQF 
embarked on a project to understand how measures are sometimes altered 
in the field leading to variation of measure specifications. In the 
second project, as financial stakes are increasingly tied to measures, 
there are growing debates about how to appropriately attribute a 
clinician's care to the outcome of the patient, made especially 
difficult when many providers contribute to the care of a single 
patient.
    Implementation and adoption of health information technology (HIT) 
is widely viewed as essential to the transformation of healthcare. As 
this field grows rapidly, it is important to recognize and understand 
the potential effects that the introduction of HIT will have on 
performance measures. While HIT presents many new opportunities to 
improve patient care and safety, it can also create new hazards and 
pose additional challenges, specifically establishing harmonized and 
consistent value sets--potentially altering measures and leaving 
validity and reliability in question.
    In 2015, NQF worked on two projects directed by HHS to advance 
eHealth Measurement: (1) The Prioritization and Identification of 
Health IT Patient Safety Measures, and (2) Value Set Harmonization.
    Variation of Measure Specifications. Measures now apply to a 
diverse range of clinical areas, settings, data sources, and programs. 
Frequently, different organizations slightly modify existing 
standardized measures to address the same fundamental quality issue. 
This leads to challenges, including confusion for stakeholders, a 
heightened burden of data collection on providers, and greater 
difficulty when trying to compare their altered measures.
    At the direction of HHS, NQF embarked on a new task order designed 
to look at currently endorsed measures and how they are used and 
modified, when the modified measure used produces data that is 
equivalent to the endorsed measures, or when the modification changes 
the measure significantly enough that the data collected is not 
comparable and essentially the modified measure is a new measure.
    In this project, NQF will convene a multistakeholder Expert Panel 
to provide leadership, guidance, and input that includes:
     Conducting an environmental scan to assess the current 
landscape of measure variation;
     Developing a conceptual framework to help identify, 
develop, and interpret variations in measure specifications and 
evaluate the effects of those variations;

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     Developing a glossary of standardized definitions for a 
limited number of key measurement terms, concepts, and components that 
are known to be common sources of variation in otherwise-similar 
measures; and
     Providing recommendations for core principles and guidance 
on how to mitigate variation and improve variability across new and 
existing measures.
    This project was awarded in October 2015 and is currently underway 
with the formation of the Expert Panel.
    Attribution. Attribution can be defined as the methodology used to 
assign patients and their quality outcomes to providers. Measurement 
approaches are needed that recognize the multiple providers involved in 
delivering care and their individual and joint responsibility to 
improve quality across the patient episode of care. These issues have 
become increasingly important with the creation and design of the 
Medicare Merit-Based Incentive Payment (MIPS) program and alternative 
payment models (APMs) for physicians under the Medicare Access and CHIP 
Reauthorization Act of 2015 (MACRA). In all of these payment 
approaches, improvements in outcomes may not be directly tied to a 
single provider.
    Increasingly, care is provided within structures of shared 
accountability, and guidance is needed regarding attribution of 
providers to patients. The issues regarding attribution to individual 
providers, which include primary care physicians, specialist 
physicians, physician groups, the role of nurse practitioners, and the 
full healthcare team, have complicated the use and evaluation of 
performance measures. HHS has directed NQF to examine this topic 
through its multistakeholder review process and commission a paper to 
include a set of principles for attribution. As the financial stakes 
tied to measures have grown, policy debates over physician payment have 
intensified. This project will synthesize and help further a better 
understanding of different approaches for addressing attribution. The 
lack of clarity in attribution approaches remains a major limitation to 
the use of outcome and cost measures.
    The Panel's final report will:
     Describe the problem that exists with respect to 
attribution of performance measurement results to one or more 
providers;
     Detail the subset of measures that are affected by 
attribution;
     Include principles that guide the selection and 
implementation of approaches to attribution;
     Put forth potential approaches that could be used to 
validly and reliably attribute performance measurement results to one 
or more providers under different delivery models; and
     Put forth models of approaches to attribution that adhere 
to the principles described above and are developed and described in 
sufficient detail to enable their testing on CMS data.
    This project was awarded in October 2015 and is currently underway.

Prioritization and Identification of Health IT Patient Safety Measures

    Increasing public awareness of HIT-related safety concerns has 
raised this issue's profile and added urgency to efforts to assess the 
scope and nature of the problem and to develop potential solutions. The 
2012 Food and Drug Administration Safety Innovation Act required 
coordinated activity between the Food and Drug Administration, the 
Office of the National Coordinator for Health Information Technology, 
and the Federal Communications Commission on a strategy to develop a 
regulatory framework for HIT that promotes patient safety, among other 
goals. These agencies' subsequent work and the HIT Policy Committee's 
recommendation to create a public-private Health IT Safety Center have 
underscored the importance of partnerships, collaboration, and shared 
responsibility in ensuring the safe use of HIT.
    An HIT-related safety event--sometimes called ``e-iatrogenesis''--
has been defined as ``patient harm caused at least in part by the 
application of health information technology.'' \ix\ Detecting and 
preventing HIT-related safety events poses many challenges because 
these are often multifaceted events, which involve not only potentially 
unsafe technological features of electronic health records, for 
example, but also user behaviors, organizational characteristics, and 
rules and regulations that guide most technology-focused activities.
    This project, launched in September 2014, assesses the current 
environment related to the measurement of HIT-related safety events and 
constructs a framework for advancement of measurement to improve the 
safety of HIT. The multistakeholder Committee for the project will work 
to:
     Explore the intersection of HIT and patient safety;
     Create a comprehensive framework for assessment of HIT 
safety measurement efforts;
     Construct a measure gap analysis; and
     Provide recommendations on how to address identified gaps 
and challenges, as well as best-practices for the measurement of HIT 
safety issues.
    The Committee adopted a three-domain framework for categorizing and 
conceptualizing potential measurement concepts and gaps in the areas of 
HIT safety, and provided a framework for recommendations around future 
HIT safety measure development. The goals of the framework are to 
ensure (1) that clinicians and patients have a foundation for safe HIT; 
(2) that HIT is properly integrated and used within the healthcare 
organizations to deliver safe care; and (3) that HIT is part of a 
continuous improvement process to make care safer and more effective. 
After receiving public input on the framework report, posted for public 
comment in November 2015, the Committee reflected upon these comments 
prior to the release of a final report in 2016.

Value Set Harmonization

    Interoperable electronic health records (EHRs) can enable the 
development and reporting of innovative performance measures that 
address critical performance and measurement gaps across settings of 
care. However, to achieve this future state, the field needs electronic 
clinical data standards and reusable ``building blocks'' of code 
vocabularies, known as value sets, to ensure measures can be 
consistently and accurately implemented across disparate systems. A 
value set consists of unique codes and descriptions which are used to 
define clinical concepts, e.g., diagnosis of diabetes, and are 
necessary to calculate Clinical Quality Measures (CQMs)--quality 
measure data gathered from a clinical setting.
    Launched in January 2015, the Committee of experts and key 
stakeholders on this project is developing a value set harmonization 
test pilot and approval process to promote consistency and accuracy in 
electronic CQM (eCQM) value sets. NQF defines value set harmonization 
as the process by which unnecessary or unjustifiable variance will be 
reduced and eventually eliminated from common value sets in eCQMs by 
the reconciliation and integration of competing and/or overlapping 
value sets. This project is guided by a multistakeholder Value Set 
Committee (VSC), as well as subject specific technical expert panels 
(TEPs).
    The VSC will help NQF to determine the overall approach to the

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harmonization and approval of value sets, including:
     The development of evaluation criteria;
     How to evaluate the results of the harmonization process; 
as well as
     Broader recommendations on how harmonized and approved 
value sets should be integrated into the measure endorsement process.
    A final report is expected in 2016.

Current State of NQF Measure Portfolio: Responding to Evolving Needs

    Across 14 HHS-funded projects in 2015, NQF endorsed 161 measures 
and removed 42 measures from its portfolio. NQF ensures that the 
measure portfolio contains ``best-in-class'' measures across a variety 
of clinical and cross-cutting topic areas. 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 because 
they are best-in-class. Working with expert multistakeholder 
committees,\x\ NQF undertakes actions to keep its endorsed measure 
portfolio relevant.
    NQF removes measures from its portfolio for a variety of reasons, 
including failure to meet more rigorous endorsement criteria, the need 
to facilitate measure harmonization and mitigate competing similar 
measures or retire measures that developers no longer wish to maintain. 
In addition, measures that are ``topped-out'' are put into reserve 
because they show consistently high levels of performance, and are 
therefore no longer meaningful in differentiating performance across 
providers. This culling of measures ensures that time is spent 
measuring aspects of care in need of improvement, rather than retaining 
measures related to areas where widespread success has already been 
achieved.
    While NQF pursues strategies to make its measure portfolio 
appropriately lean and responsive to real-time changes in clinical 
evidence, it also aggressively seeks measures from the field that will 
help to fill known measure gaps and to align with the NQS goals.
    Finally, NQF also works with developers 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 requests to report near-identical measures. 
Successful harmonization also results in fewer endorsed measures for 
providers to report and for payers and consumers to interpret. Where 
appropriate, NQF also works with measure developers to replace existing 
process measures with more meaningful outcome measures.

Measure Endorsement and Maintenance Accomplishments

    In 2015, NQF reviewed 48 new measures for endorsement and 113 
measures for the periodic maintenance review for re-endorsement. These 
measures (discussed below) were in the categories of behavioral health, 
cost and resource use, etc. As a result of this, NQF added 48 new 
measures to its portfolio, while 113 measures reviewed retained their 
NQF endorsement in 2015. Eighty-nine of the 161 endorsed measures (both 
new and renewed measures) are outcome measures (12 are patient-reported 
outcomes (PROs)), 61 are process measures, three are efficiency 
measures, three are composite measures, three are structural measures, 
and two are cost and resource use measures.
    While undergoing endorsement and maintenance, all measures are 
evaluated for their suitability based on the standardized criteria in 
the following order:
1. Evidence and Performance Gap--Importance to Measure and Report
2. Reliability and Validity--Scientific Acceptability of Measure 
Properties
3. Feasibility
4. Usability and Use
5. Comparison to Related or Competing Measures
    More information is available in the Measure Evaluation Criteria 
and Guidance for Evaluating Measures for Endorsement.\xi\
    A list of measures reviewed in 2015 and the results of the review 
are listed in Appendix A. Summaries of endorsement and maintenance 
projects completed in 2015 and projects underway but not completed in 
2015 are presented below.
Completed Projects
    Behavioral health measures. In the United States, it is estimated 
that approximately 26 percent of the population suffers from a 
diagnosable mental disorder.\xii\ These disorders--which can include 
serious mental illnesses, substance use disorders, and depression--are 
associated with poor health outcomes, increased costs, and premature 
death.\xiii\ Although general behavioral health disorders are 
widespread, the burden of serious mental illness is concentrated in 
about 6 percent of the population.\xiv\ In 2005, an estimated $113 
billion was spent on mental health treatment in the United States. Of 
that amount, $22 billion was spent on substance abuse treatment alone, 
making substance abuse one of the most costly (and treatable) illnesses 
in the nation.\xv\
    Phase 3 of the behavioral health measures project began in October 
of 2014 and concluded its endorsement process in May 2015. The Standing 
Committee evaluated 13 new measures and 6 existing measures for 
maintenance review. Measures examined in this phase dealt with tobacco 
use, alcohol and substance use, psychosocial functioning, attention 
deficit hyperactivity disorder (ADHD), depression and health screening, 
and assessment for people with serious mental illness. At the end of 
their review (which included public comment), 16 of these measures were 
endorsed by the Committee, one was approved for trial use (to further 
examine its validity), one was not recommended, and one was 
deferred.\xvi\
    Cost and resource use measures. Cost measures are a key building 
block for understanding healthcare efficiency and value. NQF has 
endorsed several cost and resource use measures since beginning 
endorsement work in the cost arena in 2009. In February 2015, NQF 
finished both phase 2 and phase 3 of the Cost and Resource Use Measures 
project.
    Phase 2 evaluated three cost and resource use measures focused on 
cardiovascular conditions--specifically the relative resource use for 
people with cardiovascular conditions, hospital-level, risk-
standardized payment associated with a 30-day episode for Acute 
Myocardial Infarction, and hospital-level, risk standardized payment 
associated with a 30-day episode-of-care heart failure. All three of 
these measures were endorsed. Two of the endorsed measures were 
endorsed with the following conditions:
     One year look-back assessment of unintended consequences. 
NQF staff is working with the Cost and Resource Use Standing Committee 
and CMS to determine a plan for assessing potential unintended 
consequences--unintended negative consequences to patients and 
populations--of these measures in use.
     Consideration for the SES trial period. The Cost and 
Resource Use Standing Committee considers whether the measures should 
be included in the NQF trial period for consideration of risk 
adjustment for socioeconomic status and other demographic factors.
     Attribution. NQF considers opportunities to address the 
attribution issue--that is, how to assign responsibility for patient 
care when multiple providers are providing care to a given 
patient.\xvii\
    In phase 3, the NQF Expert Panel evaluated three cost and resource 
use

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measures focused on pulmonary conditions, including asthma, chronic 
obstructive pulmonary disease (COPD), and pneumonia. All three of the 
measures were endorsed with the same conditions noted in this 
section.\xviii\
    Endocrine measures. Endocrine conditions most often result from the 
body producing either too much or too little of a particular hormone. 
In the United States, two of the most common endocrine disorders are 
diabetes and osteoporosis. Diabetes, a group of diseases characterized 
by high blood glucose levels, affects as many as 25.8 million Americans 
and ranks as the seventh leading cause of death in the United States. 
Many of the diabetes measures in the portfolio are among NQF's longest-
standing measures.
    Osteoporosis, a bone disease characterized by low bone mass and 
density, affects an estimated 9 percent of U.S. adults age 50 and over.
    NQF selected the endocrine measure evaluation project to pilot test 
a process improvement focused on frequent submission and evaluation of 
measures, with the goal of speeding up endorsement time and shortening 
the time from measure development to use in the field. This 25-month 
project includes three full endorsement cycles, allowing for the 
submission and review of both new and previously endorsed measures 
every six months, in contrast to usual review every three years, in a 
given topical area.
    Summarized in the final report released November 2015, the 
Endocrine Standing Committee evaluated five new measures and 18 
measures undergoing maintenance review against NQF's standard 
evaluation criteria. Of the 23 measures evaluated, 22 measures were 
recommended for endorsement by the Standing Committee and have been 
endorsed by NQF. Only one measure was not recommended for endorsement, 
Discharge Instructions--Emergency Department, because the Committee 
stated that the discharge instructions did not equate to coordination 
of care. The Committee noted that there is minimal evidence indicating 
that written discharge instructions improve care for osteoporosis 
patients or have had any impact on such outcomes as prevention of 
future fractures.\xix\
    Musculoskeletal measures. Musculoskeletal conditions include 
injuries or disorders precipitated or exacerbated by sudden exertion or 
prolonged exposure to physical factors such as repetition, force, 
vibration, or awkward postures. On average, the proportion of the U.S. 
population with a musculoskeletal disease requiring medical care has 
increased annually by more than two percentage points over the past 
decade and now includes more than 30 percent of the population.
    The Musculoskeletal Standing Committee evaluated 12 measures: Eight 
new measures and four measures undergoing maintenance review. Measures 
submitted addressed the clinical areas of rheumatoid arthritis, gout, 
pain management, and lower back injury. Three measures were recommended 
for endorsement, four measures were recommended for trial measure 
approval (an optional pathway for eMeasures being piloted in this 
project), two measures were not recommended for trial measure approval, 
one measure was not recommended for endorsement, and two measures were 
deferred for later consideration. The final report of this project was 
issued January 2015.\xx\
Continuing Projects
    Cardiovascular measures. Cardiovascular disease is the leading 
cause of death for men and women in the United States. It accounts for 
approximately $312.6 billion in healthcare expenditures annually. 
Coronary heart disease (CHD), the most common type, accounts for 1 of 
every 6 deaths in the United States. Hypertension--a major risk factor 
for heart disease, stroke, and kidney disease--affects 1 in 3 
Americans, with an estimated annual cost of $156 billion in medical 
costs, lost productivity, and premature deaths.\xxi\
    Completed August 31, 2015, the cardiovascular phase 2 project 
identified and endorsed measures for heart rhythm disorders, 
cardiovascular implantable electronic devices, heart failure, acute 
myocardial infarction, congenital heart disease, and statin medication. 
Many of the measures in the portfolio currently are used in public and/
or private accountability and quality improvement programs; however, 
significant measurement gaps remain related to cardiovascular care.
    In phase 2, the Cardiovascular Standing Committee evaluated eight 
new measures and eight measures undergoing maintenance review against 
NQF's standard evaluation criteria. Eleven of these measures were 
recommended for endorsement by the Committee, four were not 
recommended, and one was withdrawn by the developer.\xxii\
    Phase 3 of this project is still in progress. This phase is 
currently reviewing 23 measures that can be used to assess 
cardiovascular conditions at any level of analysis or setting of care, 
as well as reviewing endorsed measures scheduled for maintenance. A 
final report is expected by April 2016. Phase 4 was launched in October 
2015, with a final report expected in February of 2017. Measures are 
currently being submitted for this phase.
    Care coordination measures. Care coordination across providers and 
settings is fundamental to improving patient outcomes and making care 
more patient-centered. Poorly coordinated care can lead to unnecessary 
suffering for patients, as well as avoidable readmissions and emergency 
department visits, increased medical errors, and higher costs.
    People with chronic conditions and multiple co-morbidities--and 
their families and caregivers--often find it difficult to navigate our 
complex healthcare system. As this ever-growing population transitions 
from one care setting to another, they are more likely to suffer the 
adverse effects of poorly coordinated care. These include incomplete or 
inaccurate transfer of information, poor communication, and a lack of 
follow-up which can lead to poor outcomes, such as medication errors. 
Effective communication within and across the continuum of care will 
improve both quality and affordability.
    In July 2011, NQF launched a multiphased Care Coordination project 
focused on healthcare coordination across episodes of care and care 
transitions. Phase 1, completed in 2012, sought to address the lack of 
cross-cutting measures in the NQF measure portfolio by developing a 
path forward to more meaningful measures of care coordination 
leveraging health information technology (HIT). Phase 2 addressed the 
implementation and methodological issues in care coordination 
measurement, as well as the evaluation of 15 care coordination 
performance measures. While phase 3 was completed in December 2014, the 
Care Coordination Standing Committee is currently conducting an off-
cycle review process. An off-cycle deliberation is one that occurs 
outside of the usual timing for MAP deliberations and in which HHS 
seeks input from MAP on additional measures under consideration on an 
expedited 30-day timeline. Off-cycle measures reviewed focused on 
emergency department transfers, medication reconciliation, and timely 
transfers. These areas are key within care coordination measurement 
though do not fully address the many domains in the Care Coordination 
Framework. During the standard review process, the Coordinating 
Committee reviewed 12 measures: one new and 11 undergoing maintenance. 
A final report is expected in 2016.

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    All-cause admissions and readmissions measures. Unnecessary 
admissions and avoidable readmissions to acute-care facilities are an 
important focus for quality improvement by the healthcare system. 
Previous studies have shown that nearly 1 in 5 Medicare patients is 
readmitted to the hospital within 30 days of discharge, placing the 
patient at risk for new health problems caused by hospital-acquired 
conditions and costing upwards of $26 billion annually.\xxiii\ \xxiv\ 
Recurring admissions also can cause added stress on both patients and 
their families from lost financial income and the burden of providing 
care. Multiple entities across the healthcare system, including 
hospitals, post-acute care facilities, and skilled nursing facilities, 
all have a responsibility to ensure high-quality care transitions to 
help avoid unplanned readmissions to the hospital and unnecessary 
admissions in the first place.
    The final report for phase 2, issued in April 2015, states that the 
All-Cause Admissions and Readmissions Standing Committee endorsed 16 
measures, which marks the first time that the NQF portfolio includes 
measures examining community-level readmissions, pediatric 
readmissions, and readmissions measures in the post-acute care and 
long-term care settings.\xxv\ These measures are currently included in 
the SES trial period (see section below, Risk Adjustment for 
Socioeconomic Status and Other Demographic Factors). Phase 3 of this 
project began in October 2015 with an expected completion in 2016. 
Currently, measures to undergo evaluation for phase 3 are in the 
submission process.
    Health and well-being measures. Social, environmental, and 
behavioral factors can have significant negative impact on health 
outcomes and economic stability; yet only 3 percent of national health 
expenditures are spent on prevention, while 97 percent are spent on 
healthcare services. Population health includes a focus on health and 
well-being, along with disease and illness prevention and health 
promotion. Using the right measures can determine how successful 
initiatives are in reducing mortality and excess morbidity through 
prevention and wellness and help focus future work to improve 
population health in appropriate areas.
    With the completion of phase 1 in November 2014, phase 2 of this 
project began with a call for measures in January 2015. Currently the 
Health and Well-Being Standing Committee has seven measures under 
review, including community-level indicators of health and disease, 
health-related behaviors and practices to promote healthy living, 
modifiable socioeconomic and environmental determinants of health, and 
primary screening prevention. Phase 3 of this project was awarded in 
October 2015 with an anticipated completion date in June of 2016. Phase 
3 will review new and existing measures for endorsement in focus areas 
that include physical activity, cervical and colorectal cancer 
screenings, and adult and childhood vaccinations.
    Patient safety measures. NQF has a 10-year history of focusing on 
patient safety. NQF-endorsed patient safety measures are important 
tools for tracking and improving patient safety performance in American 
healthcare. However, gaps still remain in the measurement of patient 
safety. There is also a recognized need to expand available patient 
safety measures beyond the hospital setting and harmonize safety 
measures across sites and settings of care. In order to develop a more 
robust set of safety measures, NQF solicited patient safety measures to 
address environment-specific issues with the highest potential leverage 
for improvement.
    Phase 1 of this project concluded in January 2015 with publication 
of the final report.\xxvi\ In phase 1, NQF sought to endorse measures 
addressing gap areas on providers' approach to minimizing the risk of 
adverse events as well as to expand the measures beyond the hospital 
setting while harmonizing across sites and settings of care. The 
Patient Safety Standing Committee evaluated four new measures and 12 
measures undergoing maintenance review against NQF's standard 
evaluation criteria. In the end, eight of the measures were recommended 
for endorsement, and eight of the measures were not.
    Currently, both phase 2 and phase 3 of this project are underway. 
These phases of the project will address topic areas including, but not 
limited to, fall screening and risk management; medication 
reconciliation; patient safety measure for skilled nursing facilities, 
inpatient rehabilitation facilities, and other settings; unplanned 
admission-related measures from other settings; all-cause and 
condition-specific admission measures; condition-specific readmissions 
measures; and measures examining length of stay. Final reports for both 
phases are expected in 2016.
    Person- and family-centered care measures. Person- and family-
centered care is a core concept embedded in the National Quality 
Strategy priority: ``Ensuring that each person and family are engaged 
as partners in their care.'' Person- and family-centered care 
encompasses key outcomes of interest to patients receiving healthcare 
services. These outcomes include survival, health-related quality of 
life, functional status, symptoms and symptom burden; measures of the 
processes of care experienced by persons receiving care; as well as 
patient and family engagement in care, including shared decisionmaking 
and preparation and activation for self-care management. This project 
is focusing on patient-reported outcomes (PROs), but also may include 
some clinician-assessed functional status measures.
    NQF undertook this project in two phases. In phase 1, completed in 
March 2015, this project focused on measures of patient and family 
engagement in care, care based on patient needs and preferences, shared 
decisionmaking, and activation for self-care management. The Person- 
and Family-Centered Care Standing Committee evaluated one new measure 
and 11 measures undergoing maintenance against NQF's standard 
evaluation criteria in this first phase. At the end of phase 1, ten of 
these eleven measures were recommended for endorsement, one was no 
longer recommended for use after the Committee chose a superior measure 
addressing the same domain, and one additional measure was 
withdrawn.\xxvii\
    In phase 2, the Committee reviewed 28 measures of functional status 
and outcomes, both clinical and patient-assessed. A final report is 
expected in 2016.
    The project continues with a phase 3 and phase 4 awarded in October 
2015, and both phases are currently underway. In these phases, the 
Committee will examine clinician and patient-assessed measures of 
functional status. This new phase of work will focus on health-related 
quality of life and the communication domain of person- and family-
centered care. Currently, both phases are calling for measures.
    Surgery measures. The number of surgical procedures is increasing 
annually. In 2010, 51.4 million inpatient surgeries were performed in 
the United States; 53.3 million procedures were performed in ambulatory 
surgery centers.xxviii xxix Ambulatory surgery 
centers have been the fastest growing provider type participating in 
Medicare.xxx Surgery is one of NQF's largest portfolios in a 
given clinical condition, and many of the measures in this portfolio 
are currently in use in the public and/or private accountability and 
quality improvement programs.
    As part of NQF's ongoing work with performance measurement for 
patients

[[Page 61006]]

undergoing surgery, this project seeks to identify and endorse 
performance measures that address various surgical areas, including 
cardiac, thoracic, vascular, orthopedic, neurosurgery, urologic, and 
general surgery. This project reviewed new performance measures in 
addition to conducting maintenance reviews of surgical measures 
endorsed prior to 2012, using the most recent NQF measure evaluation 
criteria.
    In phase 1, the Surgery Measures Standing Committee evaluated a 
total of 29 measures--nine new surgical measures and 20 measures 
undergoing maintenance review. In the final report dated February 13, 
2015, 21 of these measures were recommended for endorsement (nine of 
which were recommended for reserve status) by the Committee, seven were 
not recommended, and one was withdrawn by the developer. Measures 
recommended for reserve status are ``topped out,'' meaning they are 
considered standard practice and performance is at the highest levels. 
Because they are good measures, removal is not warranted. If needed, 
they could be re-integrated into the portfolio.xxxi
    Phase 2 was completed in December 2015. This phase included 
measures in the areas of general and specialty surgery that address 
surgical processes, including pre- and post-surgical care, timing of 
prophylactic antibiotic, and adverse surgical outcomes. The Surgery 
Standing Committee evaluated four new measures, one resubmitted 
measure, and 19 measures undergoing maintenance and review. The 
Committee recommended 22 of these measures for endorsement (including 
one for reserve status); one was not recommended; and one was 
deferred.xxxii
    Phase 3 began in October 2015. This project will include 
performance measures in the areas of general and specialty surgery that 
address surgical events, including pre-, intra- and post-surgical care, 
use of medication peri-operatively, adverse surgical outcomes, and 
other related topics. Currently, a call for measures is underway.
    Eye care and ear, nose, and throat conditions measures. This 
project seeks to identify and endorse performance measures for 
accountability and quality improvement that address eye care and ear, 
nose, and throat health. Nineteen measures will undergo maintenance 
review using NQF's measure evaluation criteria.
    This project is currently in progress. Awarded in March 2015, the 
Committee is currently considering 24 measures for endorsement--
including seven eMeasures. These measures deal with the topic areas of 
glaucoma, macular degeneration, hearing screening and evaluation, and 
ear infections. Measures of interest to NQF for this project include 
outcome measures; measures applicable to more than one setting; 
measures applicable to adults and children; measures that capture data 
from broad populations; measures of chronic care management and care 
coordination for chronic conditions; and eMeasures. A final report is 
scheduled for release in 2016.
    Renal measures. Renal disease is a leading cause of mortality in 
the United States. This project identifies and endorses performance 
measures for accountability and quality improvement for renal 
conditions. Specifically, the work will examine measures that address 
conditions, treatments, interventions, or procedures relating to end-
stage renal disease (ESRD), chronic kidney disease (CKD), and other 
renal conditions. Measures that address outcomes, treatments, 
diagnostic studies, interventions, and procedures associated with these 
conditions will be considered. In addition, 21 measures will undergo 
maintenance review using NQF's measure evaluation criteria.
    Awarded in February 2015, the first phase of this project was 
completed in December 2015. The newly convened Standing Committee 
evaluated 14 NQF-endorsed measures for maintenance review and 11 new 
measures for endorsement recommendations. Fifteen measures were 
recommended for endorsement, four measures were recommended for 
endorsement with reserve status, and the Committee did not recommend 
six measures.xxxiii
    A second phase of this project was awarded in October 2015 with an 
expected completion date in April 2016. Phase 2 will continue to 
address conditions, treatments, interventions, or procedures related to 
ESRD, CKD, and other renal conditions.
New Projects in 2015
    Pediatric measures. A healthy childhood sets the stage for improved 
health and quality of life in adulthood. The Children's Health 
Insurance and Reauthorization Act of 2009 (CHIPRA) accelerated interest 
in pediatric quality measurement and presented an opportunity to 
improve the healthcare quality outcomes of the nation's children. 
CHIPRA established the Pediatric Quality Measures Program. The program, 
with support from the Agency for Healthcare Research and Quality (AHRQ) 
and CMS, funded seven Centers of Excellence to develop and refine child 
health measures in high-priority areas. After years of concerted 
effort, a selection of these measures is now ready for NQF review and 
endorsement consideration.
    The Pediatric Measures project launched in July 2015. This project 
evaluates measures related to child health that can be used for 
accountability and public reporting for all pediatric populations and 
in all settings of care. This project addresses topic areas including 
but not limited to:
     Child- and adolescent-focused clinical preventive services 
and follow-up to preventive services;
     Child- and adolescent-focused services for management of 
acute conditions;
     Child- and adolescent-focused services for management of 
chronic conditions; and
     Cross-cutting topics.
    For this project, the Committee evaluated 23 newly submitted 
measures and one previously reviewed measures against NQF's standard 
evaluation criteria. A final report is expected in 2016.
    Pulmonary/critical care. This project seeks to identify and endorse 
performance measures for accountability and quality improvement that 
address conditions, treatments, diagnostic studies, interventions, 
procedures, or outcomes specific to pulmonary conditions and critical 
care. These conditions include the areas of asthma management, COPD 
mortality, pneumonia management and mortality, and critical care 
mortality and length of stay.
    NQF currently has 25 endorsed measures in the portfolio that are 
due for maintenance and will be reevaluated against the most recent NQF 
measure criteria along with newly submitted measures. NQF has issued a 
call for measures in this topic area, with expected project completion 
in July 2016.
    Neurology. Awarded in October 2015, this project comprises outcome 
measures, measures applicable to more than one setting, measures for 
adults and children, measures that capture broad populations, measures 
of chronic care management and care coordination, and eMeasures 
specifically addressing the conditions, treatments, interventions, and 
procedures related to neurological conditions.
    The multistakeholder Standing Committee will evaluate newly 
submitted measures in the topic areas above as well as assess the 22 
NQF-endorsed measures undergoing maintenance. A final report is 
expected in September 2016.

[[Page 61007]]

    Perinatal. Despite the fact that the U.S. spends more on perinatal 
care than on any other type of care ($111 billion in 
2010),xxxiv the U.S. ranked 61st in the world for maternal 
health--suggesting that the U.S. does not get the value on return for 
its investment in perinatal health services.xxxv Research 
suggests that morbidity and mortality associated with pregnancy and 
childbirth are, to a large extent, preventable through adherence to 
existing evidence-based guidelines. Lower quality care during 
pregnancy, labor and delivery, and the postpartum period can translate 
into unnecessary complications, prolonged lengths of stay, costly 
neonatal intensive care unit (NICU) admissions, and anxiety and 
suffering for patients and families.
    This project will identify and endorse performance measures that 
specifically address the areas of reproductive health, pregnancy 
planning and contraception, pregnancy, childbirth, and postpartum and 
neonatal care. Along with new measures submitted for review, the 
Standing Committee will also evaluate 24 NQF-endorsed measures that are 
due for maintenance. Topics addressed by these endorsed measures 
include cesarean section rates, early elective deliveries, maternal and 
newborn infection rates, access to prenatal and postpartum care, 
screening measures, and breastfeeding measures. A final report is 
expected June 2016.
    Palliative care and end-of-life. NQF commenced a new project in 
October 2015 addressing the various aspects of palliative and end-of-
life care. Measures undergoing evaluation under this project include 
measures of physical, emotional, social, and spiritual aspects of care.
    In addition to new measures submitted for review and endorsement, 
16 NQF-endorsed measures will undergo maintenance and re-evaluation 
against the most recent NQF measure evaluation criteria. Measures will 
focus on, but not be limited to, access to and timeliness of care, 
patient and family experience with care, patient and family engagement, 
care planning, avoidance of unnecessary hospital or emergency 
department admissions, cost of care, and caregiver support.
    Currently, this project is underway with its call for measures. A 
final report is expected in June 2016.
    Cancer. Cancer is the second most common cause of death in the 
U.S., accounting for nearly 1 of every 4 deaths. As more Americans are 
diagnosed with cancer and new treatments have been introduced, cancer 
care has grown and evolved. In 2011, 6.7 percent of the U.S. adult 
population received cancer treatment, as compared to the 4.8 percent in 
2001.xxxvii Congruently, the cost of treating this 
population has also increased, from an estimated $56.8 billion in 2001 
to an estimated $88.3 billion in 2011.xxxviii
    As part of this endorsement project, NQF will solicit composite, 
outcome, and process measures related to desired outcomes applicable to 
any healthcare setting. The NQF multistakeholder Standing Committee 
will evaluate new measures and those undergoing maintenance in the 
following areas: breast cancer, colon cancer, chemotherapy, hematology, 
leukemia, prostate cancer, esophageal cancer, melanoma diagnosis, 
symptom management, and end-of-life care.
    Currently, there are 21 NQF-endorsed measures that will undergo 
maintenance, and a call for new measures has been issued. A final 
report is expected in January 2017.

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 multistakeholder 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, the 
consensus-based entity is to report the input of the multistakeholder 
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 (PL 111-148, 
section 3014). MAP was created to provide input to HHS on the selection 
of performance measures for more than 20 federal public reporting and 
performance-based payment programs. Launched in the spring of 2011, MAP 
is composed of representatives from more than 90 major private-sector 
stakeholder organizations, seven federal agencies, and approximately 
150 individual technical experts. For detailed information regarding 
the MAP representatives, criteria for selection to MAP, and length of 
service, please see Appendix D.
    MAP provides a forum to facilitate the private and public sectors 
to reach consensus with respect to use of measures to enhance 
healthcare value. In addition, MAP serves as an interactive and 
inclusive vehicle by which the federal government can solicit critical 
feedback from stakeholders regarding measures used in federal public 
reporting and payment programs. This approach augments CMS's 
traditional rulemaking, allowing the opportunity for substantive input 
to HHS in advance of rules being issued. Additionally, 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 provides shorter-term recommendations 
for that strategy on an annual basis. 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; and payer type.
    Since 2012, MAP has provided guidance at the request of HHS on the 
measures to be included in Medicare programs, as well as Medicaid and 
Children's Health Insurance Program (CHIP) programs nationwide. MAP 
recommendations for Medicare are considered for mandatory reporting in 
various federal programs, while recommendations to the Adult and Child 
Core Sets for Medicaid/CHIP are reported on a voluntary basis by the 
individual states. MAP also provided guidance to HHS on the use of 
performance measures to evaluate and improve care of dual eligible 
beneficiaries, who are enrolled in both Medicaid and Medicare--a 
distinct population with complex and often costly medical needs.
2015 Pre-Rulemaking Input
    MAP completed its deliberations for the 2014-15 rulemaking cycle 
with the publication of its annual report in January 2015; this was 
MAP's fourth review of measures for HHS programs. During this pre-
rulemaking process, MAP examined 199 unique measures for potential use 
in 20 different federal health programs (see Appendix C). There were 
also a number of improvements to the MAP process this year, including 
the addition of a preliminary analysis of measures; a more detailed 
examination of the needs and objectives of the programs; a more 
consistent approach to measure deliberations; and expanded public 
comment. Conducted by staff, the preliminary analysis is intended to 
provide MAP members with a succinct profile of each measure and to 
serve as a starting point for MAP discussions.

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The preliminary analysis asks a series of questions to evaluate the 
appropriateness for each measure under consideration (MUC):
     Does the MUC meet a critical program objective?
     Is the MUC fully developed?
     Is the MUC tested for the appropriate settings and/or 
level of analysis for the program? If no, could the measure be adjusted 
to use in the program's setting or level of analysis?
     Is the MUC currently in use? If yes, does a review of its 
performance history raise any red flags?
     Does the MUC contribute to the efficient use of 
measurements resources for data collection and reporting and support 
alignment across programs?
     Is the MUC NQF-endorsed for the program's setting and 
level of analysis?
    MAP has solidified its three-step process for pre-rulemaking 
deliberations:
    1. Define critical program objectives;
    2. Evaluate measures under consideration for potential inclusion in 
specific programs; and
    3. Identify and prioritize measurement gaps for programs and care 
settings.
    More specifically, in October 2014, MAP workgroups convened via 
webinar to consider each program in its setting with the goal of 
identifying its specific measurement needs and critical program 
objectives. The workgroup recommendations on critical program 
objectives were then reviewed by the Coordinating Committee in a 
November meeting.
    MAP workgroups met in person in December 2014 to evaluate the 
measures under consideration and made recommendations for use of those 
measures in various federal programs, which were then reviewed by the 
Coordinating Committee in January 2015. In their review, the 
Coordinating Committee deliberated on the workgroup recommendations as 
well as public and member comments received.
MAP Workgroups
MAP Hospital Workgroup
    MAP reviewed 81 measures under consideration for nine hospital and 
setting-specific programs: Hospital Inpatient Quality Reporting (IQR), 
Hospital Value-Based Purchasing (VBP), Hospital Readmissions Reduction 
Program (HRRP), Hospital-Acquired Condition Reduction Program (HAC), 
Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center 
Quality Reporting (ASCQR), Medicare and Medicaid EHR Incentive Program 
for Hospitals and Critical Access Hospitals (Meaningful Use), and 
Inpatient Psychiatric Facility Quality Reporting (IPFQR).
    The workgroup identified several overarching themes across the nine 
programs as it discussed individual measures. These workgroup 
deliberations are considered in MAP's pre-rulemaking recommendations to 
HHS for measures in these programs and reflect the MAP Measure 
Selection Criteria (see Appendix B), how well the measures address the 
identified program goal, and NQF's prior work to identify families of 
measures.
    First, the programs should include measures that help consumers get 
the information that they need to make informed decisions about their 
healthcare, help to direct them to facilities with the highest quality 
of care, and spur improvements in quality and efficiency.
    Second, a limited set of ``high-value measures'' allows providers 
to focus on high-priority aspects of healthcare where performance 
varies or is less than optimal. ``High-value'' measures are measures 
that are more meaningful and usable for various stakeholders and more 
likely to drive improvements in quality, including outcomes, patient-
reported outcomes (PROs), composite measures, intermediate outcome 
measures, process measures that are closely linked by empirical 
evidence to outcomes, cost and resource use measures, appropriate use 
measures, care coordination measures, and patient safety measures. The 
workgroup noted that it should support measures that add value to the 
current set and work with existing measures to improve crucial quality 
issues. It also recognized that the value of a measure should be 
assessed while considering the burden of the full measure set, further 
emphasizing the need for parsimony and alignment.
    Finally, MAP stressed the importance of aligning or using a more 
uniform set of measures across programs in order to be able to compare 
performance across settings and data types. In response to the need for 
greater alignment, MAP cautioned that the evolution of these programs 
calls for new areas of increased attention. Specifically, MAP raised a 
number of challenges to achieving alignment that need further 
consideration, including the unique program objectives of individual 
programs, updating existing measure specifications, and balancing 
shared accountability with appropriate attribution.
    MAP reviewed 81 measures and made the following recommendations for 
federal programs:
     Inpatient Quality Reporting Program--outcome measures, 
particularly readmission measures, should be reviewed in the upcoming 
NQF trial period for adjustment for SES factors;
     Hospital Value-Based Purchasing Program--the need to 
include more measures addressing high-impact areas for performance and 
quality improvement with a strong preference for NQF-endorsed measures;
     Hospital Readmissions Reduction Program--planned and 
unrelated readmissions should be excluded from measures in the program 
as are not markers of poor quality and readmissions measure generally 
should be included in the SES trial period;
     Hospital Acquired Condition Program--measures are needed 
to fill gaps that are focused on minimizing the major drivers of 
patient harm, and there is a need for greater antibiotic stewardship 
programs;
     Hospital Outpatient Quality Reporting Program--measures 
should be aligned to reduce un undue burden on providers and patients;
     Ambulatory Surgery Center Quality Reporting Program--
increased need for the development of measures in the areas of surgical 
quality, infections, complications from anesthesia-related 
complications, post-procedure follow-up, and patient and family 
engagement;
     Medicare and Medicaid EHR Incentive Program for 
Hospitals--eMeasures in the program should be valid and reliable with a 
preference for measures that go through the endorsement process--these 
measures should be assessed for comparability with measures derived 
from alternative data sources used in other programs;
     PPS-Exempt Cancer Hospital Quality Reporting Program--
measures appropriate to cancer hospitals that reflect high-priority 
service areas should align with measures in the IQR and OQR programs 
where appropriate; and
     Inpatient Psychiatric Facility Quality Reporting Program--
measurement needs to move beyond just psychiatric care at inpatient 
psychiatric facilities to include other important general medical 
conditions that affect patients with psychiatric conditions.
MAP Clinician Workgroup
    Following the same MAP pre-rulemaking criteria stated above, the 
clinician workgroup identified characteristics that are associated with 
ideal measure sets used for public reporting and payment programs for 
physicians and other clinicians. MAP reviewed 254 measures under 
consideration for two programs, the

[[Page 61009]]

Physician Quality Reporting System (PQRS) and Medicare and Medicaid EHR 
Incentive Programs (Meaningful Use).
    In past years, the clinician workgroup noted that some condition/
topic areas had more high-value measures and requested a ``scorecard'' 
process to better judge progress toward more high-value measures under 
consideration. MAP noted that clinicians who report on more high-value 
measures receive the same incentive payments even though they are 
reporting more challenging measures. Greater incentives for those who 
report on high-value measures might spur development of similar 
measures in other condition/topic areas.
    The workgroup first concluded that while noteworthy progress to 
more high-value measures has been made in a few areas, such as cardiac 
care, eye care, renal disease, and surgery, uneven or slow progress 
persisted for specific patient and other applications, such as 
individuals with multiple chronic conditions and complex conditions, 
outcome measures for cancer patients, measures for palliative/end-of-
life care, measures for eligible professionals (EPs) in the medical 
field, and EHR measures that promote interoperability and health 
information exchange.
    The workgroup felt that a greater focus on prudent alignment of 
measures across programs is essential to reduce burden and improve 
participation in quality programs. A more focused and aligned set of 
measures will also reduce confusion for users of public reporting data 
and synergize quality improvements across providers and settings of 
care. Greater focus on selecting composite measures, appropriate use 
measures, and outcome measures could promote parsimony over the number 
of measures. Calls for alignment of the measures in federal programs 
recognize the benefits of reducing data collection and reporting 
burdens on clinicians.
    Finally, the clinician workgroup concluded that financial 
incentives for many stakeholders within the quality measurement 
enterprise could yield greater development of meaningful measures. 
Specifically, MAP recommended that measure developers need ongoing 
financial support, and clinicians must invest in infrastructure to 
support the reporting of measures. This investment could drive the 
evolution of measures from basic ``building block'' measures to more 
meaningful measures. Reporting on high-value measures can pose a 
financial hardship on providers who do not have the required capacity 
or infrastructure. As a result, MAP recommended that CMS consider 
innovative incentives to further provider participation, such as 
waiving nonparticipation penalties in quality programs in exchange for 
acting as a test site or participating in a registry. For example, 
primary care and emergency medicine physicians have not yet developed 
registries despite growing pressure to do so and are seeking a business 
case that would make a registry viable. Public comments strongly 
supported the need for steady funding for measure development.
    MAP reviewed 254 clinician measures and made the following 
recommendations for federal programs:
     Physician Quality Reporting System, Physician Compare, 
Physician Value-Based Payment Modifier--include more high-value 
measures; encourage widespread participation in PQRS; measures selected 
for the program that are not NQF-endorsed should be submitted for 
endorsement; and nonendorsed measures should include measures that 
support alignment, measure outcomes that are not already addressed by 
outcome measures in the program, and be clinically relevant to 
specialties/subspecialties that do not currently have clinically 
relevant measures; and
     Medicare and Medicaid EHR Incentive Programs--include 
indorsed measures that have eMeasure specifications available; 
alignment with other federal programs particularly PQRS; and the need 
for increased focus on measures that reflect efficiency in data 
collection and reporting, measures that leverage HIT capabilities, and 
innovative measures made possible through the use of HIT.
MAP Post-Acute Care/Long-Term Care Workgroup
    MAP reviewed 19 measures under consideration for five setting-
specific federal programs addressing post-acute care (PAC) and long-
term care (LTC): the Inpatient Rehabilitation Facility Quality 
Reporting Program (IRF QRP), the Long-Term Care Hospital Quality 
Reporting Program (LTCH QRP), the End-Stage Renal Disease Quality 
Incentive Program (ESRD QIP), the Skilled Nursing Facility Value-Based 
Purchasing Program (SNF VBP), and the Home Health Quality Reporting 
Program (HH QRP). Although in previous years, MAP provided guidance on 
measures for the Hospice Quality Reporting Program (Hospice QRP), there 
were no measures under consideration for the Hospice QRP during this 
review cycle.
    Based upon the workgroup's findings, MAP defined high-leverage 
areas for performance measures and identified 13 core measure concepts 
to best address each of the high-leverage areas. Specifically, MAP 
recognized the six highest-leverage areas for PAC/LTC performance 
measurement to include function, goal attainment, patient engagement, 
care coordination, safety, and cost/access. Core measure concepts for 
each of these high-leverage areas are as follows:
     Function--functional and cognitive status assessment and 
mental health;
     Goal attainment--establishment of patient/family/caregiver 
goals, and advanced care planning and treatment;
     Patient Engagement--experience of care and shared 
decisionmaking;
     Care Coordination--transition planning;
     Safety--falls, pressure ulcers, and adverse drug events; 
and
     Cost/Access--inappropriate medicine use, infection rates, 
and avoidable admissions.
    Through the discussion of the individual measures across the five 
programs, MAP identified several overarching issues. First, PAC/LTC 
facilities should coordinate efforts with respect to patient assessment 
instruments used in PAC/LTC settings to improve and maintain the 
quality of data. Second, HHS should emphasize that harmonization of 
measures is critical to promoting patient-centered care across PAC/LTC 
programs. Finally, HHS should better align performance measurement 
across PAC/LTC settings as well as with other settings to ensure 
comparability of performance and to facilitate information exchange.
    The Improving Medicare Post-Acute Care Transformation (IMPACT) Act 
of 2014 requires certain standardized patient assessment data, data on 
quality measures, and data on resource use and other measures specified 
under sections 1899B(c)(1) and (d)(1) respectively of the Act to be 
standardized and interoperable to allow for their exchange among PAC 
providers and other providers to facilitate care coordination and 
improve Medicare beneficiary outcomes. New quality measures for these 
programs will ideally address specified core-measure concepts and more 
accurately communicate health information and care preferences when a 
patient is transferred across settings of care. MAP stressed that 
following a person across the care continuum from facility to home-
based care or beyond will allow for a better assessment of a person's 
outcomes and experience across time and settings. Additionally, the 
workgroup was generally supportive of standardizing patient assessment 
data across PAC settings; however, it noted

[[Page 61010]]

the importance of aligning measurement with other settings, such as LTC 
and home and community-based services.
    MAP reviewed 19 PAC/LTC measures and made the following 
recommendations for federal programs:
     Inpatient Rehabilitation Facility Quality Reporting 
Program--the inclusion of five measures that address patient safety and 
functional status; conditional support for four functional outcome 
measures noting that the measures are meaningful to patients and 
actionable;
     Long-Term Care Hospital Quality Reporting Program--after 
the review of three measures that addressed patient safety, one was 
recommended while the other two were encouraged to undergo continued 
development;
     End-Stage Renal Disease Quality Incentive Program--after 
the review of seven measures, three dialysis adequacy measures were 
supported as they addressed both the adult and pediatric populations 
and encourage parsimony; four measures were not supported due to 
concerns raised about feasibility in the dialysis facility setting;
     Skilled Nursing Facility Value-Based Purchasing Program--
one measure was reviewed and supported due to its alignment with 
readmissions measures in other settings;
     Home Health Quality Reporting Program--one measure was 
supported addressing pressure ulcers under the required IMPACT domain; 
and
     Hospice Quality Reporting Program--no specific measure 
recommendations but the inclusion of measures that address concepts 
such as goal attainments, patient engagement, care coordination, 
depression, caregiver roles, and timely referral to hospice were noted 
as needed for inclusion in the Hospice Item Set.
2015 MAP Off-Cycle Deliberations
    MAP convened during February 2015--in what is considered an off-
cycle review--to provide recommendations to HHS on selection of 
performance measures to meet requirements of the Improving Medicare 
Post-Acute Care Transformation (IMPACT) Act of 2014. In addition to the 
annual Measure Applications Partnership (MAP) pre-rulemaking cycle 
process, the federal government sought input from MAP on additional 
measures under consideration following an expedited 30-day timeline.
    As is noted above, the IMPACT Act, which was enacted on October 6, 
2014, requires post-acute care (PAC) providers to report certain 
standardized patient assessment data as well as data on quality, 
resource use, and other measures within domains specified in the Act. 
The Act requires, among other things, the specification of measures to 
address resource use and efficiency, such as total estimated Medicare 
spending per beneficiary, discharge to community, and measures to 
reflect all-condition risk-adjusted potentially preventable hospital 
readmission rates. Such measures are to be specified across four 
different PAC settings: Skilled nursing facilities (SNFs), inpatient 
rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and 
home health agencies (HHAs). In its deliberations, MAP highlighted the 
importance of integrating data with existing assessment instruments 
where possible, as well as noted the challenges in standardizing 
between the four different care settings.
    MAP reviewed four measures under consideration and made 
recommendations on their potential use in federal programs within the 
post-acute and long-term care settings. The first measure, Percent of 
Residents or Patients with Pressure Ulcers That Are New or Worsened 
(Short Stay), was supported by MAP as a way to address the domain of 
skin integrity and changes in skin integrity; this measure is NQF-
endorsed for the SNF, IRF, and LTCH settings.
    The second measure reviewed was the Percent of Residents 
Experiencing One or More Falls with Major Injury (Long Stay). MAP 
supported this measure, conditional upon pending proper risk 
adjustments and attribution for the home health setting to address the 
domain of incidence of major falls--addressing the IMPACT Act domain 
and a MAP PAC/LTC core concept. This measure is currently in use in the 
Nursing Home Quality Initiative. MAP also supported an All-Cause 
Readmission measure, noting that it specifically addresses an IMPACT 
Act domain and a PAC/LTC core concept.
    The final measure evaluated in the off-cycle deliberation was the 
Percent of Patients/Residents/Persons with an Admission and Discharge 
Functional Assessment and a Care Plan that Addresses Function. MAP 
conditionally supported this measure. It addresses an IMPACT Act domain 
and PAC/LTC core concept.
2015 Input on Quality Measures for Dual Eligibles
    In support of the NQS aims to provide better, more patient-centered 
care as well as improve the health of the U.S. population through 
behavioral and social interventions, HHS asked NQF to again convene a 
multistakeholder group via MAP to address measurement issues related to 
people enrolled in both the Medicare and Medicaid programs--a 
population often referred to as the ``dual eligibles'' or Medicare-
Medicaid enrollees.
    While the dual eligibles make up 20 percent of the Medicare 
population, they account for 34 percent of Medicare spending. Better 
healthcare, care coordination, and supportive services for dual 
eligible beneficiaries have the potential to make significant 
differences in their health and quality of life. Improvements for this 
population also have the potential to address the higher cost of their 
care.
    In August 2015, MAP released its sixth annual report addressing 
this population. In this report, MAP provided its latest guidance to 
HHS on the use of performance measures to evaluate and improve care 
provided to Medicare-Medicaid enrollees. MAP promotes the selection of 
aligned measures within programs by publishing a Dual Eligible Family 
of Measures. It provides a varied list of potential measures from which 
program administrators can choose a subset most appropriate to fit 
individual program needs. This workgroup reviewed a total of 22 
measures and added 18 new measures to the MAP Family of Measures for 
Dual Eligible Beneficiaries, including 12 new behavioral health 
measures, five admission/readmission measures, and one care 
coordination measure.
    To inform MAP regarding the use of measures in the Dual Eligible 
set of measures, NQF conducted an analysis to document the use of 
measures across a range of public and private programs. It revealed 
numerous measures frequently used in programs, but none focused on an 
issue that reflects the health and social complexity that sets dual 
eligible beneficiaries apart from other healthcare consumers. MAP 
recommended more rapid development of new measures for this unique 
population in topic areas such as:
     Person-centered, goal-directed care;
     access to community-based long-term supports and services; 
and
     psychosocial needs.
    The report also contained feedback from stakeholders regarding the 
use and utility of measures recommended by MAP. Through a series of 
stakeholder interviews, the report revealed that measurement is 
primarily dictated by external reporting requirements and that limited 
resources are available to conduct detailed analyses of this high-need 
population. Participants noted success in improving quality outcomes 
where they could promptly identify and

[[Page 61011]]

address barriers to access as well as unmet social needs.
    MAP favors the use of targeted, appropriate measures that can 
support program goals while driving improvement in consumer experience 
and outcomes. It recommends that HHS and other stakeholders do away 
with nonessential measurement, attestation, and regulatory requirements 
to free up system bandwidth for innovation. In its final 
recommendation, MAP suggested that wider use of measure stratification 
will allow for a better understanding of the impact of health 
disparities, for example the use of data to identify geographical 
locations by municipality or zip code that provide insight into the 
care of diverse populations, with the goal of speeding up progress in 
addressing them.
2015 Report on the Core Set of Healthcare Quality Measures for Adults 
Enrolled in Medicaid
    MAP reviewed the Medicaid Adult Core Set to identify and evaluate 
opportunities to improve the measures in use. In doing so, MAP 
considered states' feedback from the first year of implementation of 
the measures and applied its standard measure selection criteria. On 
August 31, 2015, MAP issued the final report, Strengthening the Core 
Set of Healthcare Measures for Adults Enrolled in Medicaid, 
2015.xl
    The version of the Adult Core Set for 2015 contains 26 measures, 
spanning many clinical conditions. MAP supported all but one of the 
current measures for continued use in the Adult Core Set. MAP 
recommended the removal of NQF-endorsed measure #0648 Timely 
Transmission of Transition Record (Discharges from an Inpatient 
Facility to Home/Self Care or Any Other Site of Care) due to reports of 
low feasibility and lack of reporting by states.
    In addition, MAP supported or conditionally supported nine measures 
for phased addition over time to the measure set spanning many clinical 
areas including behavioral health, reproductive health, and treatment 
options for those with terminal illnesses. MAP is aware that additional 
federal and state resources are required for each new measure; 
therefore, the task force recommended that measures be ranked to 
provide a clear sense of priority based on the expert opinions of the 
group on the most important measures to report. Additionally, many 
important priorities for quality measurement and improvement do not yet 
have metrics available to properly address them.
Strengthening the Core Set of Healthcare Quality Measures for Children 
Enrolled in Medicaid and CHIP, 2015
    HHS awarded NQF additional work in 2015 to assess and strengthen 
the Child Core Set. Using a similar approach to its review of the Adult 
Core Set, MAP performed an expedited review over a period of 10 weeks 
to provide input to HHS within the 2015 federal fiscal year (FFY). MAP 
considered states' feedback from their ongoing participation in the 
voluntary reporting program and applied its standard measure selection 
criteria to identify opportunities to improve the Child Core Set. The 
final report titled, Strengthening the Core Set of Healthcare Quality 
Measures for Children Enrolled in Medicaid and CHIP, 
2015,xli was issued August 31, 2015.
    The 2015 Child Core Set contains 24 measures representing the 
diverse health needs of the Medicaid and CHIP enrollee population, 
spanning many clinical topic areas. The measures are relevant to 
children ages 0-18 as well as pregnant women in order to encompass both 
prenatal and postpartum quality-of-care issues. Not finding significant 
implementation difficulties, MAP supported all of the FFY 2015 Child 
Core Set measures for continued use. In addition, MAP recommended that 
CMS consider up to six measures for phased implementation, allowing 
providers more time to prepare for data collection and reporting 
without creating undue burden on providers and their practices, 
specifically in the topic areas of perinatal care, behavioral health, 
pediatric health, and readmissions.
V. Cross-Cutting Challenges Facing Measurement: Gaps in Endorsed 
Quality and Efficiency Measures Across HHS Programs
    Under section 1890(b)(5)(iv) of the Act, the entity is required to 
describe in the annual report 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 HHS under the National Quality Strategy and where 
targeted research may address such gaps.
Identifying Gaps in the NQF Portfolio
    In October 2015, a team of NQF staff worked to assess current gap 
areas within the portfolio, a byproduct of NQF measure endorsement and 
selection work, as well as gaps in new areas. After careful review, NQF 
staff identified 254 measure gaps; some of these gap areas may be 
addressed through recently launched projects.
    The topic areas with the largest number of gaps reported are 
Neurology, Cancer, Behavioral Health, Care Coordination, and Resource 
Use. These gaps can persist for many reasons, including lack of measure 
development due to a funder's priorities or agendas, lack of a champion 
for these gap areas, limitation on data sources, particularly for those 
measures that require data that does not come from administrative 
claims or charts, and measure gap areas such as care coordination and 
resource use that are difficult to conceptualize and may require new 
methodologies. Both neurology and cancer projects have announced a call 
for measures. Additionally, care coordination and cost and resource use 
measures can be cross-cutting and apply to multiple disease-specific 
areas and practice portfolios.
    For a full list of the NQF portfolio gaps identified, refer to 
Appendix F.
    In a separate but related process, each MAP workgroup has 
identified measure gaps in their respective areas, as well as 
considered efforts related to alignment and reducing disparities that 
may be better addressed by risk adjustment and stratification. These 
need to be considered in light of the gaps identified through the 
endorsement process.
Measure Applications Partnership: Identifying and Filling Measurement 
Gaps, Alignment, and Addressing Disparities
    Building upon MAP's ongoing role in identifying gaps in 
measurement, MAP developed a scorecard approach which quantifies the 
number of MAP-recommended measures in gap areas. The 2015 scorecard is 
in Appendix E. Organized by the priority areas of the National Quality 
Strategy, the scorecard shows that MAP recommended multiple measures in 
some gap areas, while underscoring that measures are still needed in 
other important areas. Notable areas with a many gaps include the 
clinical quality measures in cancer and cardiovascular conditions, care 
coordination and communication, safety--particularly hospital acquired 
infections (HAI), medication and pain management, and person- and 
family-centered care--and the use of shared decisionmaking and care 
planning.

[[Page 61012]]

    This high-level summary provided by the scorecard can help identify 
which gaps are starting to be addressed and where more work remains.
    MAP members outlined several ways to strengthen the gap-filling 
approach in its deliberations. They included: (1) Identify where 
measures are not available or inadequately assess performance; (2) 
prioritize gaps by importance, impact, and feasibility; and (3) 
highlight barriers to gap-filling, such as infrastructure support 
needs, and offer potential solutions to these barriers. Each area-
specific working group weighed in on the gaps in the Clinician, 
Hospital, and PAC/LTC spaces along with the Medicaid and CHIP programs.
MAP Clinician Federal Program Summaries
    In this year's MAP deliberations, members noted that measurement 
gaps could arise when measures are removed from programs. For example, 
this year more than 50 measures were removed from the Physician Quality 
Reporting System (PQRS) across a variety of condition areas. These 
removals could lead to measurement gaps, and programs should be 
subjected to ongoing scrutiny and analysis to ensure that they continue 
to assess important areas. This scrutiny is of particular importance 
for clinician programs, which seek to have relevant measures across all 
clinical specialties. Public commenters shared this concern and 
suggested monitoring to assure that removal would not leave a gap in 
measurement. In the PQRS program, there is an increased need for 
outcome rather than process measures as well as measures that address 
patient safety and adverse events, appropriate use of diagnosis and 
therapeutics, efficiency, cost, and resource use.
    MAP also suggested critical improvements to the program objectives 
of the Value-Based Payment Modifier and Physician Feedback of Quality 
Resource and Use Reports (QRURs). MAP suggested that these programs use 
measures that have been reported for at least one year, and ideally can 
be linked with particular cost or resource use measures to capture 
value. Also, MAP suggested that there should be a greater focus on 
monitoring the unintended consequences to vulnerable populations.
    Similarly, MAP identified the need for greater focus on outcome 
measures and measures that are meaningful to consumers and purchasers 
for the Physician Compare Initiative--with a focus on patient 
experience, patient-reported outcomes (e.g., functional status), care 
coordination, population health (e.g., risk assessment, prevention), 
and appropriate care measures.
    Finally, with the rapidly growing world of electronic health 
records (EHRs), MAP identified a few key areas of measurement focus for 
the Medicare and Medicaid EHR Incentive Programs for EPs. MAP suggested 
including more measures that have eMeasure specifications available. 
Moving forward, MAP also noted that the clinician level programs should 
focus on measures that reflect efficiency in data collection and 
reporting through the use of health IT, measures that leverage health 
IT capabilities, and innovative measures made possible by health IT.
MAP Hospital Federal Programs
    Priority measure gaps for the Ambulatory Surgical Center Quality 
Reporting (ASCQR) Program include surgical quality care, infection 
rates, follow-up after procedures, complications including anesthesia-
related complications, cost, and patient and family engagement measures 
including an Ambulatory Surgical Center (ASC)-specific Consumer 
Assessment of Healthcare Providers and Systems (CAHPS) module and 
patient-reported outcomes.
    MAP suggested that for the Hospital Acquired Condition (HAC) 
Reduction program measures should focus on reducing major drivers of 
harm. Measures used by both HAC Reduction Program and the Hospital VBP 
Program can help to focus attention on critical safety issues.
    Several gap areas were identified by MAP for the Hospital VBP 
Program. These gaps include medication errors, mental and behavioral 
health, emergency department throughput, a hospital's culture of 
safety, and patient and family engagement.
    MAP suggested several areas for increased work and development for 
the Hospital Readmissions Reduction Program. Improved care transitions, 
increased care coordination across providers, and improved 
communication of important inpatient information to those who will be 
taking care of the patient post-discharge are measure areas that could 
benefit from further development in order to reduce readmissions.
    Measure gaps in the Inpatient Psychiatric Facility Quality 
Reporting (IPFQR) program include step down care--care provided between 
hospital discharge and full immersion back into the home and 
community--behavioral health assessments and care in the emergency 
department (ED), readmissions, identification and management of general 
medical conditions, partial hospitalization or day programs, and a 
psychiatric care module for CAHPS.
    Gaps identified in the Hospital Outpatient Quality Reporting (OQR) 
Program measure set include measures of ED overcrowding, wait times, 
and disparities in care--specifically, disproportionate use of EDs by 
vulnerable populations. Other gaps include measures of cost, patient-
reported outcomes, patient and family engagement, follow-up after 
procedures, fostering important ties to community resources to enhance 
care coordination efforts, and an outpatient CAHPS module.
    Finally, MAP identified several gaps in the PPS-Exempt Cancer 
Hospital Quality Reporting (PCHQR) Program. These measures should 
address gaps in cancer care including pain screening and management, 
patient and family/caregiver experience, patient-reported symptoms and 
outcomes, survival, shared decisionmaking, cost, care coordination, and 
psychosocial/supportive services.
MAP PAC/LTC Federal Programs
    MAP carried forward the recommendation from last year's pre-
rulemaking deliberations for the Nursing Home Quality Initiative (NHQI) 
program. There is still a need for added measures that assess discharge 
to the community and the quality of transition planning, as well as the 
inclusion of the nursing home-CAHPS measures in the program to address 
patient experience.
    Under the Home Health Quality Reporting Program (HHQRP), while no 
specific measure gaps were identified, MAP recommended that CMS conduct 
a thorough analysis of the measure set to identify priority gap areas, 
measures that are topped out, and opportunities to improve the existing 
measures.
    Consistent with the previous year, MAP states that the Inpatient 
Rehabilitation Facility Quality Reporting Program (IRFQRP) measure set 
is still too limited and could be enhanced by addressing core measure 
concepts not currently in the set such as care coordination, functional 
status, and medication reconciliation and the safety issues that have 
high incidence in IRFs, such as MRSA, falls, CAUTI and Clostridium 
Difficile (C. diff). Similarly, the LTC Hospitals Quality Reporting 
Program (LTCH QRP) recommendations continue from the previous year. 
Measures that address cost, cognitive status assessment, medication

[[Page 61013]]

management, and advance directives need to be developed.
    MAP made recommendations for the future directions for the End-
Stage Renal Disease Quality Incentive Program (ESRDQIP). MAP prefers to 
include more outcome measures and pediatric measures to assess the 
pediatric population that has been largely excluded from the existing 
measures, and sees a need to identify appropriate data elements and 
sources to support measures. Similarly, MAP made recommendations for 
the future direction of the HHQRP. These recommendations include the 
development of an outcome measure addressing pain and the selection of 
measures that address care coordination, communication, timeliness/
responsiveness, responsiveness of care, and access to the healthcare 
team on a 24-hour basis.
Gaps in Measures for Dual Eligible Beneficiaries
    During its deliberations, the task force convened to address the 
needs of Dual Eligible beneficiaries identified high-priority gaps in 
the family of measures for Dual Eligibles. The list of gaps identified 
this year has not changed since the previous report, Dual Eligible 
Beneficiary Population Interim Report 2012. This consistency emphasizes 
that new and improved measures are still urgently needed to evaluate:
     Goal-directed, person-centered care planning and 
implementation;
     Shared decisionmaking;
     Systems to coordinate acute care, long-term services and 
supports;
     Beneficiary sense of control/autonomy/self-determination;
     Psychosocial needs; and
     Optimal functioning levels.
Gaps in the Medicaid Adult Core Set
    During its deliberations on the current state of the Medicaid Adult 
Core Set, MAP documented the following gaps (in no particular order of 
priority) that need to be filled in order to further strengthen the 
core set of measures:
     Access to primary, specialty, and behavioral healthcare;
     Beneficiary reported outcomes--health-related quality of 
life;
     Care coordination including the integration of medical and 
psychosocial services, and primary care and behavioral integration;
     Efficiency, specifically the inappropriate use of the 
emergency department (ED);
     Long-term supports and services, notably HCBS;
     Maternal health--inter-conception care to address risk 
factors, poor birth outcomes; postpartum complications, support with 
breastfeeding after hospitalization;
     Promotion of wellness;
     Treatment outcomes for behavioral health conditions and 
substance use disorders;
     Workforce;
     New chronic opiate use (45 days);
     Polypharmacy;
     Engagement and activation in healthcare; and
     Trauma-informed care.
Gaps in the Medicaid Child Core Set
    As with Adult Core Set, many important priorities for quality 
measurement and improvement do not have the metrics available to 
address them. The following measure gaps (in no particular order of 
priority) will be a starting point for future discussion and will guide 
annual revisions to further strengthen the Child Core Set:
     Care coordination--HCBS, social service coordination, and 
cross-sector measures that would foster joint accountability with the 
education and criminal justice systems;
     Screening for abuse and neglect;
     Injuries and trauma;
     Mental health--notably access to outpatient and ambulatory 
mental health services, ED use for behavioral health, and behavioral 
health functional outcomes that stem from trauma-informed care;
     Overuse/medically unnecessary care--specifically 
appropriate use of CT scans;
     Durable medical equipment; and
     Cost measures--targeting people with chronic needs and 
family out-of-pocket spending.
Progress in Aligning Measurement Requirements
    During this year's deliberations, the MAP discussions centered on 
the need for measurement alignment across multiple programs by focusing 
on having standardized measures that allow for comparing performance 
across care settings, data sources, and standardized definitions for 
measure elements--the core items needed for comprehensive assessment 
within the measure.
    MAP noted the usefulness of expanding certain hospital programs to 
allow small and rural hospitals the ability to report measures, thus 
closing potential ``reporting gaps'' across the healthcare system. The 
recommendations in the report, Performance Measurement for Rural Low-
Volume Providers (see section above, Rural Health), address this 
issue.xliii Additionally, MAP noted that true alignment goes 
beyond having similar concepts, but requires aligned technical 
specifications. Currently, providers report measure performance using a 
variety of data sources, including from EHR-based measures to 
registries to claims-based measures. Alignment would ensure that 
results are comparable regardless of the data source used.
    However in their discussions, MAP members also noted the limits of 
alignment. Some measurement programs may have specific purposes which 
necessitate the use of specialized measures. Moreover, there were 
questions about what constituted alignment, such as whether measures 
need to be exactly the same or could differ slightly and still be 
considered comparable.
    The public comments NQF received on the recommendations of the 
workgroups reflected appreciation for MAP's recognition of the 
importance of alignment and further emphasized the need to simplify 
measures across settings--leveraging consistency of similar measures 
used in multiple programs. Other comments centered on the importance of 
aligning measures on the national and the state/regional level--
emphasizing a need to understand measure variation between payers.
Difficulty of Disparities
    MAP also raised the issue of the need to better assess disparities. 
Many measures could be stratified for different populations or 
conditions to understand the nature and extent of variations in measure 
results. However, the data currently available may not contain all the 
information needed to allow for meaningful measure stratification. This 
often hampers the efforts to address health disparities. Further work 
is required to specify and build the data infrastructure needed to 
fully understand variations and disparities in care delivery and health 
outcomes.

VI. Coordination With Measurement Initiatives Implemented by Other 
Payers

    Section1890(b)(5)(A)(i) of the Social Security Act mandates that 
the Annual Report to Congress and the Secretary include a description 
of the implementation of quality and efficiency measurement initiatives 
under this Act and the coordination of such initiatives with quality 
and efficiency initiatives implemented by other payers.
    This year NQF worked with other payers and entities to better 
understand the areas of alignment and socioeconomic risk adjustment of

[[Page 61014]]

measures in an effort to coordinate quality measurement across the 
public and private sectors.
Private and Public Alignment
    Beginning in 2014, CMS and America's Health Insurance Plans (AHIP) 
have brought together private- and public-sector payers to work on 
better measure alignment between the two sectors.
    The stakeholders formed a variety of working groups charged with 
the mission to foster measure alignment in those clinical areas. The 
working groups address the specific areas of accountable care 
organizations and patient-centered medical homes, cardiology, 
obstetrics and gynecology, oncology, orthopedics, gastroenterology, 
ophthalmology, HIV and Hepatitis C, and pediatrics. Nearly all the 
measures that have been identified for alignment purposes are NQF-
endorsed.
    Their focus has been on clinician level measures and has largely 
been oriented toward measures used in ambulatory settings. As the 
endorser of measures, NQF contributed technical assistance to these 
working groups. The guidance that NQF provided centered on the current 
status of the portfolio and the individual measures.
    Fostering greater measure alignment is a goal shared by many 
stakeholders. While these working groups are not intended to solve the 
alignment conundrum, they will serve as an important first step toward 
accomplishing this lofty and much needed goal. A report from the AHIP-
CMS Core Measures Group is expected in 2016; however, no specific 
deadline has been publicized.
Risk Adjustment for Socioeconomic Status (SES) and Other Demographic 
Factors
    Risk adjustment (also known as case-mix adjustment) refers to 
statistical methods to control or account for patient-related factors 
when computing performance measure scores. Risk adjusting outcome 
performance measures to account for differences in patient health 
status and clinical factors that are present at the start of care is 
widely accepted. There has been growing interest from policymakers and 
other healthcare leaders regarding whether measures used in comparative 
performance assessments, including public reporting and pay-for-
performance, should be adjusted for socioeconomic status and other 
demographic factors (SES) in order to improve the comparability of 
performance. Because patient-related factors can have an important 
influence on patient outcomes, risk adjustment can improve the ability 
to make an accurate and fair conclusion about the quality of care 
patients receive.
    In January 2015, NQF's Cost and Resource Use Standing Committee and 
All-Cause Admissions and Readmissions Standing Committee convened to 
discuss the NQF Board's recommendations regarding measures endorsed 
with conditions (see page 20). NQF staff also briefed measure 
developers on the need for a conceptual and empirical evaluation of 
potential measures for inclusion in a trial period. This two-year trial 
period is a temporary policy change that will allow risk adjustment of 
performance measures for SES and other demographic factors. At the 
conclusion of the trial, NQF will determine whether to make this policy 
change permanent.
    In April 2015, the SES trial officially opened for all newly 
submitted measures, as well as measures undergoing endorsement 
maintenance review and measures already in the trial period. Measures 
included the SES trial are the aforementioned all cause admission/
readmission and cost/resource use measures, as well as cardiovascular 
measures. For measures included in the trial period, measure developers 
are requested to provide information on socioeconomic and other related 
factors that were available and analyzed during measure development. 
However, not all measures are prime for inclusion in the trial. There 
must be a sound conceptual and empirical basis to be included in the 
SES adjustment trial. The conceptual basis for inclusion refers to a 
logical theory that explains the association between an SES factor(s) 
and the outcome of interest--it may be informed by prior research and/
or healthcare experience related to the measure focus, but a direct 
causal relationship is not required.
    Measures that are selected for this trial period have been reviewed 
under the regular endorsement and maintenance process prescribed by 
statute and have been granted a conditional endorsement based on the 
appropriate risk adjustment and stratification of the measures to 
account for socioeconomic status and other demographic factors.

VII. Conclusion and Looking Forward

    NQF has evolved in the 16 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, its 
role has expanded. New roles have included providing private sector 
input into the development of the National Quality Strategy, defining 
measure gaps, and recommending measures for an array of public 
programs. What has also changed is the centrality of performance 
measures in efforts by public and private policymakers to transform 
delivery and payment systems. In essence, performance measures are 
becoming more and more consequential.
    NQF's work in evolving the science of performance measurement has 
also expanded over the years, and recent projects focus on challenges 
that stand in the way of getting to high-value outcome and cost 
measures, as well as bringing new kinds of providers into 
accountability programs. More specifically, this year NQF launched 
projects focused on attribution and variation, which will provide 
important guidance to developers and those implementing measures, 
respectively. And an Expert Panel made recommendations on how best to 
include rural and low-volume providers in accountability programs over 
the next number of years and suggested particular considerations that 
should be taken into account in doing so.
    In 2015, NQF's work also focused on helping to facilitate the 
transition to eMeasurement. Efforts in this area included encouraging 
the submission of eMeasures for endorsement, creating a framework to 
help advance the notion of using measures to improve the safety of 
health information technology, and facilitating the development of 
evaluation criteria and an overall approach to the harmonization and 
approval of value sets, the ``building blocks'' of code vocabularies, 
to ensure measures can be consistently and accurately implemented 
across disparate HIT systems.
    Moving forward into 2016, NQF looks forward to addressing other 
issues that stymie our collective efforts to use eMeasures, continuing 
our progress in addressing measurement science challenges, and 
furthering the portfolio of high-value measures that public and private 
payers, providers, and patients rely on to improve health and 
healthcare.

Appendix A: 2015 Activities Performed Under Contract With HHS

[[Page 61015]]



                       1. Recommendations on the National Quality Strategy and Priorities
----------------------------------------------------------------------------------------------------------------
                                                                                            Notes/Scheduled or
             Description                        Output                   Status          actual  completion date
----------------------------------------------------------------------------------------------------------------
Multistakeholder input on a National   A common framework that  Phase 2 in progress....  Phase 2 in progress.
 Priority: Improving Population         offers guidance on
 Health by Working with Communities.    strategies for
                                        improving population
                                        health within
                                        communities.
Quality measurement for home and       Report will provide a    In progress............  Final report due
 community-based services.              conceptual framework                              September 2016.
                                        and environmental scan
                                        to address performance
                                        measure gaps in home
                                        and community-based
                                        services to enhance
                                        the quality of
                                        community living.
Rural Health.........................  A report exploring       Completed..............  Final report issued
                                        quality reporting                                 September 2015.
                                        improvements in rural
                                        communities.
----------------------------------------------------------------------------------------------------------------


                                2. Quality and Efficiency Measurement Initiatives
----------------------------------------------------------------------------------------------------------------
                                                                                            Notes/scheduled or
             Description                        Output                   Status          actual  completion date
----------------------------------------------------------------------------------------------------------------
Behavioral health measures...........  Set of endorsed          Phase 3 completed......  Phase 2 endorsed 16
                                        measures for                                      measures in May 2015.
                                        behavioral health.
Cost and resource use measures.......  Set of endorsed          Phase 2 completed......  Phase 2 endorsed 1
                                        measures for cost and   Phase 3 completed......   measure fully; and 2
                                        resource use.                                     measures with
                                                                                          conditions in February
                                                                                          2015.
                                                                                         Phase 3 endorsed 3
                                                                                          measures with
                                                                                          conditions in February
                                                                                          2015.
Endocrine measures...................  Set of endorsed          Phase 3 completed......  Phase 3 endorsed 22
                                        measures for endocrine                            measures in November
                                        conditions.                                       2015.
Musculoskeletal measures.............  Set of endorsed          Completed..............  Endorsed 3 measures
                                        measures for                                      fully; 4 measures
                                        musculoskeletal                                   recommended for trial
                                        conditions.                                       approval in January
                                                                                          2015.
Cardiovascular measures..............  Set of endorsed          Phase 2 completed......  Phase 2 endorsed 11
                                        measures for            Phase 3 in progress....   measures in August
                                        cardiovascular                                    2015.
                                        conditions.
Care coordination measures...........  Set of endorsed          Phase 3 completed......  Currently in off-cycle
                                        measures for care                                 review
                                        coordination.
All-cause admission and readmissions   Set of endorsed          Phase 2 completed......  Endorsed 16 measures in
 measures.                              measures for all-cause  Phase 3 in progress....   April 2015 with
                                        admissions and                                    conditions.
                                        readmissions.
Patient safety measures..............  Set of endorsed          Phase 1 completed......  Phase 1 endorsed 8
                                        measures for patient    Phase 2 in progress....   measures in January
                                        safety.                 Phase 3 in progress....   2015.
Person- and family-centered care       Set of endorsed          Phase 1 completed        Phase 1 endorsed 10
 measures.                              measures for person-     January 2015.            measures in January
                                        and family-centered     Phase 2 in progress....   2015.
                                        care.                   Phase 3 in progress....
                                                                Phase 4 in progress....
Surgery measures.....................  Set of endorsed          Phase 1 completed        Phase 1 endorsed 21
                                        measures for surgery.    February 2015.           measures in February
                                                                Phase 2 completed         2015.
                                                                 December 2015.          Phase 2 endorsed 22
                                                                Phase 3 in progress....   measures in December
                                                                                          2015.
Eye care and ear, nose, and throat     Set of endorsed          In progress............  Final report will be
 conditions measures.                   measures for eye care,                            completed in January
                                        ear, nose, and throat                             2016.
                                        conditions.
Renal measures.......................  Ent of endorsed measure  Phase 1 completed......  Phase 1 endorsed 15
                                        for renal care.         Phase 2 in progress....   measures and 4
                                                                                          measures recommended
                                                                                          for reserve status.
Pulmonary/critical care measures.....  Set of endorsed          In progress............  Final report expected
                                        measures for pulmonary/                           October 2016.
                                        critical care.
Neurology measures...................  Set of endorsed          In progress............  Final report expected
                                        measures for neurology.                           November 2016.
Perinatal measures...................  Set of endorsed          In progress............  Final report expected
                                        measures for perinatal                            January 2017.
                                        care.
Palliative and end-of-life measures..  Set of endorsed          In progress............  Final report expected
                                        measures for                                      January 2017.
                                        palliative and end-of-
                                        life measures.
Cancer measures......................  Set of endorsed          In progress............  Final report expected
                                        measures for cancer                               January 2017.
                                        care.

[[Page 61016]]

 
Variation of measure specifications..  Environmental scan,      In progress............  Final report expected
                                        conceptual framework,                             December 2016.
                                        glossary of
                                        definitions, and
                                        recommendation of core
                                        principles.
Attribution..........................  Set principles for       In progress............  Final report expected
                                        attribution and                                   December 2016.
                                        explore valid and
                                        reliable approaches
                                        for attribution,
                                        develop model that
                                        meets the requirements
                                        set.
Risk adjustment for socioeconomic      Assessment of            Trial period in          .......................
 status or other demographic factors.   appropriate risk         progress.
                                        adjustment
                                        stratification
                                        standards.
Prioritization and identification of   Comprehensive framework  In progress............  Final report expected
 health IT patient safety measures.     for assessment of HIT                             February 2016.
                                        safety measurement and
                                        provide
                                        recommendations on
                                        gaps.
Value set harmonization..............  Development of           In progress............  Final report expected
                                        evaluation criteria,                              March 2016.
                                        recommendations on
                                        integration.
Rural health.........................  This project provided    Completed..............  Final report completed
                                        recommendations to HHS                            in September 2015.
                                        on performance
                                        measurement issues for
                                        rural and low-volume
                                        providers.
----------------------------------------------------------------------------------------------------------------


            3. Stakeholder Recommendations on Quality and Efficiency Measures and National Priorities
----------------------------------------------------------------------------------------------------------------
                                                                                            Notes/Scheduled or
             Description                        Output                   Status          actual  completion date
----------------------------------------------------------------------------------------------------------------
Recommendations for measures to be     Measure Applications     Completed..............  Completed January 2015.
 implemented through the federal        Partnership pre-
 rulemaking process for public          pulemaking
 reporting and payment.                 recommendations on
                                        measures under
                                        consideration by HHS
                                        for 2015 rulemaking.
Recommendations for measures to be     Measure Applications     In progress............  .......................
 implemented through the federal        Partnership pre-
 rulemaking process for public          pulemaking
 reporting and payment.                 recommendations on
                                        measures under
                                        consideration by HHS
                                        for 2016 rulemaking.
Identification of quality measures     Annual input on the      Completed..............  Completed August 2015.
 for dual-eligible Medicare-Medicaid    Initial Core Set of
 enrollees and adults enrolled in       Health Care Quality
 Medicaid.                              Measures for Adults
                                        Enrolled in Medicaid,
                                        and additional
                                        refinements to
                                        previously published
                                        Families of Measures.
Identification of quality measures     Annual input on the      In progress............  Completed August 2015.
 for children in Medicaid.              Initial Core Set of
                                        Health Care Quality
                                        Measures for Children
                                        enrolled in Medicaid.
----------------------------------------------------------------------------------------------------------------

Appendix B: MAP Measure Selection Criteria

    The Measure Selection Criteria (MSC) are intended to assist MAP 
with identifying characteristics that are associated with ideal 
measure sets used for public reporting and payment programs. The MSC 
are not absolute rules; rather, they are meant to provide general 
guidance on measure selection decisions and to complement program-
specific statutory and regulatory requirements. Central focus should 
be on the selection of high-quality measures that optimally address 
the National Quality Strategy's three aims, fill critical 
measurement gaps, and increase alignment. Although competing 
priorities often need to be weighed against one another, the MSC can 
be used as a reference when evaluating the relative strengths and 
weaknesses of a program measure set, and how the addition of an 
individual measure would contribute to the set. The MSC have evolved 
over time to reflect the input of a wide variety of stakeholders.
    To determine whether a measure should be considered for a 
specified program, the MAP evaluates the measures under 
consideration against the MSC. MAP members are expected to 
familiarize themselves with the criteria and use them to indicate 
their support for a measure under consideration.
    1. NQF-endorsed measures are required for program measure sets, 
unless no relevant endorsed measures are available to achieve a 
critical program objective demonstrated by a program measure set 
that contains measures that meet the NQF endorsement criteria, 
including importance to measure and report, scientific acceptability 
of measure properties, feasibility, usability and use, and 
harmonization of competing and related measures.
 Subcriterion 1.1 Measures that are not NQF-endorsed should 
be submitted for endorsement if selected to meet a specific program 
need
 Subcriterion 1.2 Measures that have had endorsement removed 
or have been

[[Page 61017]]

submitted for endorsement and were not endorsed should be removed 
from programs
 Subcriterion 1.3 Measures that are in reserve status (i.e., 
topped out) should be considered for removal from programs
    2. Program measure set adequately addresses each of the National 
Quality Strategy's three aims demonstrated by a program measure set 
that addresses each of the National Quality Strategy (NQS) aims and 
corresponding priorities. The NQS provides a common framework for 
focusing efforts of diverse stakeholders on:
 Subcriterion 2.1 Better care, demonstrated by patient- and 
family-centeredness, care coordination, safety, and effective 
treatment
 Subcriterion 2.2 Healthy people/healthy communities, 
demonstrated by prevention and well-being
 Subcriterion 2.3 Affordable care
    3. Program measure set is responsive to specific program goals 
and requirements demonstrated by a program measure set that is ``fit 
for purpose'' for the particular program.
 Subcriterion 3.1 Program measure set includes measures that 
are applicable to and appropriately tested for the program's 
intended care setting(s), level(s) of analysis, and population(s)
 Subcriterion 3.2 Measure sets for public reporting programs 
should be meaningful for consumers and purchasers
 Subcriterion 3.3 Measure sets for payment incentive 
programs should contain measures for which there is broad experience 
demonstrating usability and usefulness (Note: For some Medicare 
payment programs, statute requires that measures must first be 
implemented in a public reporting program for a designated period)
 Subcriterion 3.4 Avoid selection of measures that are 
likely to create significant adverse consequences when used in a 
specific program
 Subcriterion 3.5 Emphasize inclusion of endorsed measures 
that have eMeasure specifications available
    4. Program measure set includes an appropriate mix of measure 
types demonstrated by a program measure set that includes an 
appropriate mix of process, outcome, experience of care, cost/
resource use/appropriateness, composite, and structural measures 
necessary for the specific program.
 Subcriterion 4.1 In general, preference should be given to 
measure types that address specific program needs
 Subcriterion 4.2 Public reporting program measure sets 
should emphasize outcomes that matter to patients, including 
patient- and caregiver-reported outcomes
 Subcriterion 4.3 Payment program measure sets should 
include outcome measures linked to cost measures to capture value
    5. Program measure set enables measurement of person- and 
family-centered care and services demonstrated by a program measure 
set that addresses access, choice, self-determination, and community 
integration.
 Subcriterion 5.1 Measure set addresses patient/family/
caregiver experience, including aspects of communication and care 
coordination
 Subcriterion 5.2 Measure set addresses shared 
decisionmaking, such as for care and service planning and 
establishing advance directives
 Subcriterion 5.3 Measure set enables assessment of the 
person's care and services across providers, settings, and time
    6. Program measure set includes considerations for healthcare 
disparities and cultural competency demonstrated by a program 
measure set that promotes equitable access and treatment by 
considering healthcare disparities. Factors include addressing race, 
ethnicity, socioeconomic status, language, gender, sexual 
orientation, age, or geographical considerations (e.g., urban vs. 
rural). Program measure set also can address populations at risk for 
healthcare disparities (e.g., people with behavioral/mental 
illness).
 Subcriterion 6.1 Program measure set includes measures that 
directly assess healthcare disparities (e.g., interpreter services)
 Subcriterion 6.2 Program measure set includes measures that 
are sensitive to disparities measurement (e.g., beta blocker 
treatment after a heart attack), and that facilitate stratification 
of results to better understand differences among vulnerable 
populations
    7. Program measure set promotes parsimony and alignment 
demonstrated by a program measure set that supports efficient use of 
resources for data collection and reporting, and supports alignment 
across programs. The program measure set should balance the degree 
of effort associated with measurement and its opportunity to improve 
quality.
 Subcriterion 7.1 Program measure set demonstrates 
efficiency (i.e., minimum number of measures and the least 
burdensome measures that achieve program goals)
 Subcriterion 7.2 Program measure set places strong emphasis 
on measures that can be used across multiple programs or 
applications (e.g., Physician Quality Reporting System [PQRS], 
Meaningful Use for Eligible Professionals, Physician Compare)

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

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

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

    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 consider more focused topics, 
such as developing ``families of measures''--related measures that 
cross settings and populations--and provide further information to 
the MAP Coordinating Committee and workgroups. Each multistakeholder 
group includes individuals with content expertise and organizations 
particularly affected by the work.
    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 nonvoting because federal officials cannot advise 
themselves. MAP members serve staggered three-year terms.

MAP Coordinating Committee

Committee Co-Chairs (Voting)

George J. Isham, MD, MS
Elizabeth A. McGlynn, Ph.D., MPP

Organizational Members (Voting)

AARP
    Joyce Dubow, MUP
Academy of Managed Care Pharmacy
    Marissa Schlaifer, RPh, MS
AdvaMed
    Steven Brotman, MD, JD
AFL-CIO
    Shaun O'Brien
American Board of Medical Specialties
    Lois Margaret Nora, MD, JD, MBA
American College of Physicians
    Amir Qaseem, MD, Ph.D., MHA
American College of Surgeons
    Frank G. Opelka, MD, FACS
American Hospital Association
    Rhonda Anderson, RN, DNSc, FAAN
American Medical Association
    Carl A. Sirio, MD
American Medical Group Association
    Sam Lin, MD, Ph.D., MBA
American Nurses Association

[[Page 61018]]

    Marla J. Weston, Ph.D., RN
America's Health Insurance Plans
    Aparna Higgins, MA
Blue Cross and Blue Shield Association
    Trent T. Haywood, MD, JD
Catalyst for Payment Reform
    Shaudi Bazzaz, MPP, MPH
Consumers Union
    Lisa McGiffert
Federation of American Hospitals
    Chip N. Kahn, III
Healthcare Financial Management Association
    Richard Gundling, FHFMA, CMA
Healthcare Information and Management Systems Society
    To be determined
The Joint Commission
    Mark R. Chassin, MD, FACP, MPP, MPH
LeadingAge
    Cheryl Phillips. MD, AGSF
Maine Health Management Coalition
    Elizabeth Mitchell
National Alliance for Caregiving
    Gail Hunt
National Association of Medicaid Directors
    Foster Gesten, MD, FACP
National Business Group on Health
    Steve Wojcik
National Committee for Quality Assurance
    Margaret E. O'Kane, MHS
National Partnership for Women and Families
    Alison Shippy
Pacific Business Group on Health
    William E. Kramer, MBA
Pharmaceutical Research and Manufacturers of America (PhRMA)
    Christopher M. Dezii, RN, MBA, CPHQ

Individual Subject Matter Experts (Voting)

    Bobbie Berkowitz, Ph.D., RN, CNAA, FAAN
    Marshall Chin, MD, MPH, FACP
    Harold A. Pincus, MD
    Carol Raphael, MPA

Federal Government Liaisons (Nonvoting)

Agency for Healthcare Research and Quality (AHRQ)
    Richard Kronich, Ph.D./Nancy J. Wilson, MD, MPH
Centers for Disease Control and Prevention (CDC)
    Chesley Richards, MD, MH, FACP
Centers for Medicare & Medicaid Services (CMS)
    Patrick Conway, MD, MSc
Office of the National Coordinator for Health Information Technology 
(ONC)
    Kevin Larsen, MD, FACP

MAP Clinician Workgroup

Committee Chair (Voting)

Mark McClellan, MD, Ph.D.
    The Brookings Institution, Engelberg Center for Health Care 
Reform

Organizational Members (Voting)

The Alliance
    Amy Moyer, MS, PMP
American Academy of Family Physicians
    Amy Mullins, MD, CPE, FAAFP
American Academy of Nurse Practitioners
    Diane Padden, Ph.D., CRNP, FAANP
American Academy of Pediatrics
    Terry Adirim, MD, MPH, FAAP
American College of Cardiology
    *Representative to be determined
American College of Emergency Physicians
    Jeremiah Schuur, MD, MHS
American College of Radiology
    David Seidenwurm, MD
Association of American Medical Colleges
    Janis Orlowski, MD
Center for Patient Partnerships
    Rachel Grob, Ph.D.
Consumers' CHECKBOOK
    Robert Krughoff, JD
Kaiser Permanente
    Amy Compton-Phillips, MD
March of Dimes
    Cynthia Pellegrini
Minnesota Community Measurement
    Beth Averbeck, MD
National Business Coalition on Health
    Bruce Sherman, MD, FCCP, FACOEM
National Center for Interprofessional Practice and Education
    James Pacala, MD, MS
Pacific Business Group on Health
    David Hopkins, MS, Ph.D.
Patient-Centered Primary Care Collaborative
    Marci Nielsen, Ph.D., MPH
Physician Consortium for Performance Improvement
    Mark L. Metersky, MD
Wellpoint
    *Representative to be determined

Individual Subject Matter Experts (Voting)

Luther Clark, MD
    Subject Matter Expert: Disparities
    Merck & Co., Inc
Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
    Subject Matter Expert: Palliative Care
    Hospice and Palliative Nurses Association
Eric Whitacre, MD, FACS; Surgical Care
    Subject Matter Expert: Surgical Care
    Breast Center of Southern Arizona

Federal Government Liaisons (Nonvoting)

Centers for Disease Control and Prevention (CDC)
    Peter Briss, MD, MPH
Centers for Medicare & Medicaid Services (CMS)
    Kate Goodrich, MD
Health Resources and Services Administration (HRSA)
    Girma Alemu, MD, MPH

Dual Eligible Beneficiaries Workgroup Liaison (Nonvoting)

Humana, Inc.
    George Andrews, MD, MBA, CPE, FACP, FACC, FCCP

MAP Coordinating Committee Co-Chairs Members (Voting, Ex-Officio)

HealthPartners
    George J. Isham, MD, MS
Kaiser Permanente
    Elizabeth A. McGlynn, Ph.D., MPP

MAP Hospital Workgroup

Committee Chairs (Voting)

Frank G. Opelka, MD, FACS (Chair)
Ronald S. Walters, MD, MBA, MHA, MS (Vice-Chair)

Organizational Members (Voting)

Alliance of Dedicated Cancer Centers
    Karen Fields, MD
American Federation of Teachers Healthcare
    Kelly Trautner
American Hospital Association
    Nancy Foster
American Organization of Nurse Executives
    Amanda Stefancyk Oberlies, RN, MSN, MBA, CNML, Ph.D.(c)
America's Essential Hospitals
    David Engler, Ph.D.
ASC Quality Collaboration
    Donna Slosburg, BSN, LHRM, CASC
Blue Cross Blue Shield of Massachusetts
    Wei Ying, MD, MS, MBA
Children's Hospital Association
    Andrea Benin, MD
Memphis Business Group on Health
    Cristie Upshaw Travis, MHA
Mothers Against Medical Error
    Helen Haskell, MA
National Coalition for Cancer Survivorship
    Shelley Fuld Nasso
National Rural Health Association
    Brock Slabach, MPH, FACHE
Pharmacy Quality Alliance
    Shekhar Mehta, PharmD, MS
Premier, Inc.
    Richard Bankowitz, MD, MBA, FACP
Project Patient Care
    Martin Hatlie, JD
Service Employees International Union
    Jamie Brooks Robertson, JD
St. Louis Area Business Health Coalition
    Louise Y. Probst, MBA, RN

Individual Subject Matter Experts (Voting)

Dana Alexander, RN, MSN, MBA
Jack Fowler, Jr., Ph.D.
Mitchell Levy, MD, FCCM, FCCP
Dolores L. Mitchell
R. Sean Morrison, MD
Michael P. Phelan, MD, FACEP
Ann Marie Sullivan, MD

Federal Government Liaisons (Nonvoting)

Agency for Healthcare Research and Quality (AHRQ)
    Pamela Owens, Ph.D.
Centers for Disease Control and Prevention (CDC)
    Daniel Pollock, MD
Centers for Medicare & Medicaid Services (CMS)
    Pierre Yong, MD, MPH

Dual Eligible Beneficiaries Workgroup Liaison (Nonvoting)

University of Pennsylvania School of Nursing
    Nancy Hanrahan, Ph.D., RN, FAAN

MAP Coordinating Committee Co-Chairs Members (Voting, Ex-Officio)

HealthPartners
    George J. Isham, MD, MS
Kaiser Permanente
    Elizabeth A. McGlynn, Ph.D., MPP
MAP Post-Acute Care/Long-Term Care Workgroup

Committee Chair (Voting)

    Carol Raphael, MPA

Organizational Members (Voting)

Aetna
    Joseph Agostini, MD

[[Page 61019]]

American Medical Rehabilitation Providers Association
    Suzanne Snyder Kauserud, PT
American Occupational Therapy Association
    Pamela Roberts, Ph.D., OTR/L, SCFES, CPHQ, FAOTA
American Physical Therapy Association
    Roger Herr, PT, MPA, COS-C
American Society of Consultant Pharmacists
    Jennifer Thomas, PharmD
Caregiver Action Network
    Lisa Winstel
Johns Hopkins University School of Medicine
    Bruce Leff, MD
Kidney Care Partners
    Allen Nissenson, MD, FACP, FASN, FNKF
Kindred Healthcare
    Sean Muldoon, MD
National Consumer Voice for Quality Long-Term Care
    Robyn Grant, MSW
National Hospice and Palliative Care Organization
    Carol Spence, Ph.D.
National Pressure Ulcer Advisory Panel
    Arthur Stone, MD
National Transitions of Care Coalition
    James Lett, II, MD, CMD
Providence Health & Services
    Dianna Reely
Visiting Nurses Association of America
    Margaret Terry, Ph.D., RN

Individual Subject Matter Experts (Voting)

Louis Diamond, MBChB, FCP(SA), FACP, FHIMSS
Gerri Lamb, Ph.D.
Marc Leib, MD, JD
Debra Saliba, MD, MPH
Thomas von Sternberg, MD

Federal Government Liaisons (Nonvoting)

Centers for Medicare & Medicaid Services (CMS)
    Alan Levitt, MD
Office of the National Coordinator for Health Information Technology 
(ONC)
    Elizabeth Palena Hall, MIS, MBA, RN
Substance Abuse and Mental Health Services Administration (SAMHSA)
    Lisa C. Patton, Ph.D.

Dual Eligible Beneficiaries Workgroup Liaison (Nonvoting)

Consortium of Citizens with Disabilities
    Clarke Ross, DPA

MAP Coordinating Committee Co-Chairs Members (Voting, Ex-Officio)

HealthPartners
    George J. Isham, MD, MS
Kaiser Permanente
    Elizabeth A. McGlynn, Ph.D., MPP

MAP Medicaid Adult Task Force

Chair (Voting)

Harold Pincus, MD

Organizational Members (Voting)

Academy of Managed Care Pharmacy
    Marissa Schlaifer
American Academy of Family Physicians
    Alvia Siddiqi, MD, FAAFP
American Academy of Nurse Practitioners
    Sue Kendig, JD, WHNP-BC, FAANP
America's Health Insurance Plans
    Kirstin Dawson
Humana, Inc.
    George Andrews, MD, MBA, CPE, FACP
March of Dimes
    Cynthia Pellegrini
National Association of Medicaid Directors
    Daniel Lessler, MD, MHA, FACP
National Rural Health Association
    Brock Slabach, MPH, FACHE

Individual Subject Matter Expert Members (Voting)

Anne Cohen, MPH
Nancy Hanrahan, Ph.D., RN, FAAN
Marc Leib, MD, JD
Ann Marie Sullivan, MD

Federal Government Members (Nonvoting, Ex-Officio)

Centers for Medicare & Medicaid Services
    Marsha Smith, MD, MPH, FAAP
Substance Abuse and Mental Health Services Administration (SAMHSA)
    Lisa Patton, Ph.D.

MAP Medicaid Child Task Force

Chairs (Voting)

Foster Gesten, MD

Organizational Members (Voting)

Aetna
    Sandra White, MD, MBA
American Academy of Family Physicians
    Alvia Siddiqi, MD, FAAFP
American Academy of Pediatrics
    Terry Adirim, MD, MPH, FAAP
American Nurses Association
    Susan Lacey, RN, Ph.D., FAAN
American's Essential Hospitals
    Denise Cunill, MD, FAAP
Blue Cross and Blue Shield Association
    Carole Flamm, MD, MPH
Children's Hospital Association
    Andrea Benin, MD
Kaiser Permanente
    Jeff Convissar, MD
March of Dimes
    Cynthia Pellegrini
National Partnership for Women and Families
    Carol Sakala, Ph.D., MSPH

Individual Subject Matter Expert Members (Voting)

Luther Clark, MD
Anne Cohen, MPH
Marc Leib, MD, JD

Federal Government Members (Nonvoting, Ex-Officio)

Agency for Healthcare Research and Quality
    Denise Dougherty, Ph.D.
Health Resources and Services Administration
    Ashley Hirai, Ph.D.
Office of the National Coordinator for Health IT
    Kevin Larsen, MD, FACP

MAP Dual Eligible Beneficiaries Workgroup

Co-Chairs (Voting)

Jennie Chin Hansen, RN, MS, FAAN
Alice Lind, MPH, BSN

Organizational Members (Voting)

AARP Public Policy Institute
    Susan Reinhard, RN, Ph.D., FAAN
American Federation of State, County and Municipal Employees
    Sally Tyler, MPA
American Geriatrics Society
    Gregg Warshaw, MD
American Medical Directors Association
    Gwendolen Buhr, MD, MHS, MEd, CMD
America's Essential Hospitals
    Steven Counsell, MD
Center for Medicare Advocacy
    Kata Kertesz, JD
Consortium for Citizens with Disabilities
    E. Clarke Ross, DPA
Humana, Inc.
    George Andrews, MD, MBA, CPE
iCare
    Thomas H. Lutzow, Ph.D., MBA
National Association of Social Workers
    Joan Levy Zlotnik, Ph.D., ACSW
National PACE Association
    Adam Burrows, MD
SNP Alliance
    Richard Bringewatt

Individual Subject Matter Expert Members (Voting)

Mady Chalk, MSW, Ph.D.
Anne Cohen, MPH
James Dunford, MD
Nancy Hanrahan, Ph.D., RN, FAAN
K. Charlie Lakin, Ph.D.
Ruth Perry, MD
Gail Stuart, Ph.D., RN

Federal Government Members (Nonvoting, Ex-Officio)

Office of the Assistant Secretary for Planning and Evaluation
    D.E.B. Potter, MS
Centers for Medicare & Medicaid Services
    Venesa J. Day
Administration for Community Living
    Jamie Kendall, MPP

Appendix E: Measurement Gaps Identified by MAP

    As published in the Cross-Cutting Challenges Facing Measurement: 
MAP 2015 Guidance report, March 2015. Available at http://www.qualityforum.org/Publications/2015/03/Cross-Cutting_Challenges_Facing_Measurement_-_MAP_2015_Guidance.aspx.

------------------------------------------------------------------------
     Condition/topic area                   Measurement gap
------------------------------------------------------------------------
                              Affordability
------------------------------------------------------------------------
Costs for Special Populations  End-of-life care including inappropriate
                                nonpalliative services at the end of
                                life.
                               Chemotherapy appropriateness, including
                                dosing.

[[Page 61020]]

 
                               Use of radiographic imaging in the
                                pediatric population.
                               Addressing intense needs for care and
                                support of medically complex populations
                                (e.g., ability to obtain preventive
                                services, medications, mental health,
                                oral health, and specialty services).
Efficient Use of Services....  Appropriateness for admissions,
                                treatment, over-diagnosis, under-
                                diagnosis, misdiagnosis, imaging, and
                                procedures.
                               AHRQ ambulatory sensitive conditions
                                measures.
                               Utilization benchmarking.
                               Potentially inappropriate medication use:
                                Antibiotic use for sinusitis Unwarranted
                                maternity care interventions (C-
                                section).
                               Measures derived from Choosing Wisely.
                               Availability of lower cost alternatives.
Employer/Purchaser Costs.....  Employer spending on employee health
                                benefits.
                               Measure of lost productivity.
Patient Costs................  Consideration of patient out-of-pocket
                                cost.
                               Ability to obtain follow-up care.
Total Costs..................  Per capita total cost for attributed
                                patients.
                               Converging macro/national total cost data
                                with provider-/setting-/service area-
                                specific/patient-/third-party payer
                                total cost.
------------------------------------------------------------------------
                            Care Coordination
------------------------------------------------------------------------
Avoidable Admissions and       Shared accountability and attribution
 Readmissions.                  across the continuum.
Communication................  Bi-directional sharing of relevant/
                                adequate information across all
                                providers and settings.
                               Measures of patient transition to next
                                provider/site of care across all
                                settings, as well as transitions to
                                community services.
System and Infrastructure....  Interoperability of EHRs to enhance
                                communication.
                               Structures to connect health systems and
                                benefits.
                               Emergency department overcrowding/wait
                                times (focus on disproportionate use by
                                vulnerable populations).
------------------------------------------------------------------------
                             Healthy Living
------------------------------------------------------------------------
Behaviors....................  Healthy lifestyle behaviors (i.e.,
                                avoiding excessive alcohol use, avoiding
                                tobacco, improving nutrition, engaging
                                in physical activity, etc.).
General......................  Public health preparedness.
Health/Wellness Status.......  Sense of control/autonomy/self-
                                determination/well-being.
                               Treatment burden (i.e., difficulty with
                                healthcare management tasks).
Social and Environmental       Community role; patient's ability to
 Determinants of Health.        connect to available resources.
                               Social connectedness for people with long-
                                term services and supports needs.
                               Nutrition/Food Security
------------------------------------------------------------------------
      Prevention and Treatment for the Leading Causes of Mortality
------------------------------------------------------------------------
Special Populations..........  Pediatric measures.
General......................  Complications such as febrile neutropenia
                                and surgical site infection.
Cancer.......................  Outcome measures for cancer patients
                                (e.g., cancer- and stage-specific
                                survival as well as patient-reported
                                measures).
                               Transplants: Bone marrow and peripheral
                                stem cells.
                               Staging measures for lung, prostate, and
                                gynecological cancers.
                               Marker/drug combination measures for
                                marker-specific therapies, performance
                                status of patients undergoing oncologic
                                therapy/pre-therapy assessment.
                               Disparities measures, such as risk-
                                stratified process and outcome measures,
                                as well as access measures.
Cardiovascular...............  Clinical preventive services--assessing
                                cardio-metabolic risk factors across all
                                levels of analysis and settings.
                               Appropriateness of coronary artery bypass
                                graft and PCI at the provider and system
                                levels of analysis.
                               Early detection of heart failure
                                decompensation.
                               Medication management and adherence as
                                part of follow-up care for secondary
                                prevention.
Depression...................  Suicide risk assessment for any type of
                                depression diagnosis Assessment and
                                referral for substance use.
                               Medication adherence and persistence for
                                all behavioral health conditions.
Diabetes.....................  Measures addressing glycemic control for
                                complex patients across settings and
                                level of analysis.
                               Sequelae of diabetes.
General......................  Measures of diagnostic accuracy.
                               Behavioral health assessments and care.
Musculoskeletal..............  Evaluating bone density, and prevention
                                and treatment of osteoporosis in
                                ambulatory settings.
Primary and Secondary          Outcomes of smoking cessation
 Prevention.                    interventions.
                               Lifestyle management (e.g., physical
                                activity/exercise, diet/nutrition).
                               Modify Prevention Quality Indicators
                                (PQI) measures to assess accountable
                                care organizations; modify population to
                                include all patients with the disease
                                (if applicable).
------------------------------------------------------------------------

[[Page 61021]]

 
                                 Safety
------------------------------------------------------------------------
Falls and Immobility.........  Standard definition of falls across
                                settings to avoid potential confusion
                                related to two different fall rates.
                               Structural measures of staff availability
                                to ambulate and reposition patients,
                                including home care providers and home
                                health aides.
General......................  Composite measure of most significant
                                Serious Reportable Events.
                               Measures for antibiotic stewardship.
HAI..........................  Pediatric population: special
                                considerations for ventilator-associated
                                events and C. difficile.
                               Infection measures reported as rates,
                                rather than ratios.
                               Sepsis (healthcare-acquired and community-
                                acquired) incidence, early detection,
                                monitoring, and failure to rescue
                                related to sepsis.
                               Ventilator-associated events across
                                settings.
                               Post-discharge follow-up on infections in
                                ambulatory settings.
                               Vancomycin Resistant Enterococci (VRE)
                                measures (e.g., positive blood cultures,
                                appropriate antibiotic use).
------------------------------------------------------------------------
Medication/Infusion Safety...  Potentially inappropriate medication use.
                               Medication management: Medication
                                documentation, including appropriate
                                prescribing and comprehensive medication
                                review.
                               Adverse Drug Events: Total number of
                                adverse drug events that occur within
                                all settings.
                               Role of community pharmacist or home
                                health provider in medication
                                reconciliation.
General......................  Blood incompatibility.
Obstetrical Adverse Events...  Obstetrical adverse event index.
                               Measures using National Health Safety
                                Network (NHSN) definitions for
                                infections in newborns.
Pain Management..............  Effectiveness of pain management balanced
                                by monitoring for potentially
                                inappropriate use of opioids.
                               Assessment of depression with pain.
Perioperative/Procedural       Air embolism.
 Safety.                       Perioperative respiratory events, blood
                                loss, and unnecessary transfusion.
                               Altered mental status in perioperative
                                period.
                               Anesthesia events (inter-operative
                                myocardial infarction, corneal abrasion,
                                broken tooth, etc.)
Venous Thromboembolism.......  VTE outcome measures for ambulatory
                                surgical centers and post-acute care/
                                long-term care settings.
                               Adherence to VTE medications, monitoring
                                of therapeutic levels, medication side
                                effects, and recurrence.
------------------------------------------------------------------------
                    Person- and Family-Centered Care
------------------------------------------------------------------------
Person-Centered Communication  Information provided at appropriate
                                times.
                               Information is aligned with patient
                                preferences.
                               Patient understanding of information.
                               Outreach to ensure ability for care self-
                                management.
Shared Decisionmaking, Care    Person-centered care plan.
 Planning, and Other Aspects   Integration of patient/family values in
 of Person-Centered Care.       care planning.
                               Plan agreed to by the patient and
                                provider and given to patient.
                               Care plan shared among all involved
                                providers.
                               Identified primary provider responsible
                                for the care plan.
                               Fidelity to care plan and attainment of
                                goals.
                               Social care planning addressing all needs
                                for patient and caregiver Grief and
                                bereavement care planning.
                               Patient activation/engagement.
Advanced Illness Care........  Symptom management.
                               Comfort at end of life.
Quality of Life and            Functional status.
 Functional Status.            Pain and symptom management.
                               Health-related quality of life.
                               Achievement of goals (i.e., experience,
                                progression towards goals, efficiency).
                               Step down care.
------------------------------------------------------------------------

Appendix F: NQF Portfolio Identified Gaps

------------------------------------------------------------------------
            Topic area                         Measurement gap
------------------------------------------------------------------------
All...............................  Measures that assess functional
                                     status/symptoms for Alzheimer's
                                     Disease.
All...............................  Absence of experience-of-care and
                                     quality-of-life measures.
Behavioral Health.................  Measures for family caregivers
                                     (dementia).
Behavioral Health.................  Outcome measures, especially those
                                     regarding quality of life and
                                     experience with care (dementia).
Behavioral Health.................  Measures of health and well-being
                                     for family caregivers (dementia).
Behavioral Health.................  Person- and family-centered
                                     measures, including measures of
                                     engagement with the healthcare
                                     system or other community support
                                     systems (dementia).

[[Page 61022]]

 
Behavioral Health.................  Screening for alcohol and drugs,
                                     specifically using tools such as
                                     the Screening Brief Intervention
                                     and Referral to Treatment (SBIRT).
Behavioral Health.................  Screening for post-traumatic stress
                                     disorder and bi-polar with patients
                                     diagnosed with depression.
Behavioral Health.................  Expanding the target populations to
                                     include adolescent patients aged 13
                                     years and older rather than those
                                     only aged 18 and older.
Behavioral Health.................  Measures specific to child and
                                     adolescent behavioral health needs;
                                     in particular, a measure on primary
                                     care screening and appropriate
                                     follow-up for behavioral health
                                     disorders in children.
Behavioral Health.................  Outcome measures for substance abuse/
                                     dependence that can be used by
                                     substance use specialty providers.
Behavioral Health.................  Quality measures assessing care for
                                     persons with an intellectual
                                     disabilities across the lifespan.
Behavioral Health.................  Quality measures that better align
                                     indicators of clinical need and
                                     treatment selection and, ideally,
                                     incorporate patient preferences.
Behavioral Health.................  Measures that assess aspects of
                                     recovery-oriented care for
                                     individuals with serious mental
                                     illness.
Behavioral Health.................  Quality measures related to
                                     coordination of care across sectors
                                     involved in the care or support of
                                     persons with chronic mental health
                                     problems (general medical care,
                                     mental health care, substance abuse
                                     care and social services).
Behavioral Health.................  Adapt measure concepts that have
                                     been developed for and applied to
                                     inpatient care to other outpatient
                                     care settings (e.g., polypharmacy,
                                     follow up after discharge).
Behavioral Health.................  Quality measures that assess whether
                                     evidence-based psychosocial
                                     interventions are being applied
                                     with a level of fidelity consonant
                                     with their evidence base.
Behavioral Health.................  Expand the number of conditions for
                                     which the quality of care can be
                                     assessed in the context of a
                                     ``measurement-based care'' approach
                                     (as is possible now with the suite
                                     of measures that have been endorsed
                                     for depression).
Behavioral Health.................  Further develop measurement
                                     strategies for assessing the
                                     adequacy of screening and
                                     prevention interventions for
                                     general medical conditions among
                                     individuals with severe mental
                                     illness (as well as care for their
                                     co-morbid general medical
                                     conditions).
Behavioral Health.................  Screening for alcohol and drugs,
                                     specifically using tools such as
                                     the Screening Brief Intervention
                                     and Referral to Treatment (SBIRT).
Behavioral Health.................  Screening for post-traumatic stress
                                     disorder (PTSD). and bipolar
                                     disorder in all patients diagnosed
                                     with depression, attempting to
                                     differentiate between the
                                     disorders.
Behavioral Health.................  A measure assessing gaps in local
                                     service areas (i.e., does the
                                     immediate local area have the
                                     ability to help a patient with
                                     specific behavioral health needs?).
Behavioral Health.................  Outcome measures that assess
                                     improvement in depressive symptoms.
Cancer............................  Primary care measures that screen
                                     for multiple behavioral health
                                     disorders.
Cancer............................  A measure examining a patient's
                                     ability to access specialty care.
Cancer............................  Measures of community tenure,
                                     assessing how long patients who
                                     frequently readmit stay out of
                                     hospitals between admissions.
Cancer............................  Measures aimed at the elderly
                                     population that attempt to
                                     distinguish behavioral health
                                     conditions and intellectual issues
                                     related to aging.
Cancer............................  PSA screenings for patients
                                     diagnosed with prostate cancer.
Cancer............................  Measures addressing hematological
                                     malignancies, particularly first
                                     line therapies.
Cancer............................  Measures addressing targeted
                                     therapies for kidney and lung
                                     cancer, as well as other solid
                                     tumor cancers.
Cancer............................  Measures capturing deviations in
                                     care for the CMS priority areas of
                                     prostate, lung, breast, and colon
                                     cancers.
Cancer............................  Measures addressing management of
                                     complications such as febrile
                                     neutropenia (FN).
Cancer............................  Measures for pediatric patients,
                                     including measures in cross-cutting
                                     areas such as pain assessment and
                                     palliative care.
Cancer............................  Measures ensuring that reporting
                                     details in pathology reports are
                                     standardized across all tumor
                                     types.
Cancer............................  Measures ensuring that treatment
                                     summaries are standardized across
                                     medical and radiation oncologists.
Cancer............................  Measures capturing enrollment of
                                     patients in clinical trials at
                                     appropriate times.
Cancer............................  Measures addressing whether
                                     appropriate patients are offered
                                     enrollment in clinical trials.
Cancer............................  Measures capturing access of
                                     patients to high-quality hospice
                                     care facilities.
Cancer............................  Measures addressing readmissions and
                                     value-based care.
Cancer............................  Measures of care coordination.
Cancer............................  Measures capturing patient-reported
                                     outcomes.
Cancer............................  Measures capturing cancer survival
                                     rate curve measures that can be
                                     reported by stage, identified as
                                     both overall survival (OS) and
                                     disease free survival (DFS).
Cancer............................   Measures applicable to
                                     patients with:
                                    [cir] lung, pancreas, liver,
                                     esophagus, and colon cancer: 5-year
                                     survival rates
                                    [cir] breast cancer: 10-year
                                     survival rates
                                    [cir] thyroid cancer: 20-25 year
                                     survival rates.
Cancer............................  Measures capturing operating room
                                     procedures or processes that need
                                     to take place in the surgical
                                     theater.
Cancer............................  Measures capturing patient adherence
                                     to prescribed medications or
                                     therapies, including oral
                                     chemotherapies.
Cancer............................  Measures capturing treatment of
                                     negative side effects from
                                     prescribed medications or
                                     therapies.
Cancer............................  Measures capturing gene mutations
                                     and appropriate therapies.
Cancer............................  Measures capturing use of biological
                                     therapies.
Cancer............................  Outcome measures rather than process
                                     measures.
Cancer............................  Measures capturing surgical
                                     outcomes.
Cancer............................  Measures capturing surgical
                                     processes linked to outcomes.
Cancer............................  Measures assessing the quality of
                                     laboratory methodologies.
Cancer............................  Measures assessing the quality of
                                     laboratory reports.
Cancer............................  Measures addressing maintenance of
                                     nutritional status throughout the
                                     course of treatment.

[[Page 61023]]

 
Cancer............................  Measures capturing smoking cessation
                                     for patients with lung cancers.
Cancer............................  Evidence-based measures related to
                                     surveillance of cancer survivors in
                                     order to minimize the probability
                                     of recurrence.
Cancer............................  Measures related to cancer survival
                                     in specific areas, e.g., smoking
                                     cessation for lung cancer patients;
                                     maintaining nutritional status.
Cancer............................  Measures related to the quality,
                                     value, and effectiveness of
                                     surgical, radiation, and medical
                                     therapies in cancer care over the
                                     course of treatment.
Cancer............................  Measures related to predictive
                                     laboratory testing.
Cancer............................  Measures addressing pediatric
                                     patients with cancer.
Cancer............................  Measures addressing hematological
                                     cancers separately from other
                                     cancers.
Cancer............................  Measures addressing disparities
                                     stratified by race/ethnicity,
                                     gender, and language.
Cardiovascular....................  Measures submitted by patient
                                     advocacy groups or other
                                     multidisciplinary stakeholders.
Cardiovascular....................  Prevention measures.
Cardiovascular....................  Screening measures.
Cardiovascular....................  Combined measures to be used in
                                     ``toolkits'' to ensure a process is
                                     associated with an improved
                                     outcome.
Cardiovascular....................  Measures of cardiometabolic risk
                                     factors.
Cardiovascular....................  Patient-reported outcome measures
                                     for heart failure symptoms and
                                     activity assessment.
Care Coordination.................  Composite measures for heart failure
                                     care.
Care Coordination.................  ``episode of care'' composite
                                     measure for AMI that includes
                                     outcome as well as process
                                     measures.
Care Coordination.................  Consideration of socioeconomic
                                     determinants of health and
                                     disparities.
Care Coordination.................  Global measure of cardiovascular
                                     care.
Care Coordination.................  Document care recipient's current
                                     supports and assets.
Care Coordination.................  Linkages and synchronization of care
                                     and services.
Care Coordination.................  Individuals' progression toward
                                     goals for their health and quality
                                     of life.
Care Coordination.................  A comprehensive assessment process
                                     that incorporates the perspective
                                     of a care recipient and his care
                                     team.
Care Coordination.................  Shared accountability within a care
                                     team.
Care Coordination.................  Measures of patient-caregiver
                                     engagement.
Care Coordination.................  Measures that evaluate ``system-
                                     ness'' rather than measures that
                                     address care within silos.
Care Coordination.................  Outcome measures.
Care Coordination.................  Composite measures.
Care Coordination.................  Measure maturity (more complexity in
                                     care coordination measures).
Care Coordination.................  Using measurement to drive practice.
Care Coordination.................  Patient-reported outcomes.
Care Coordination.................  Capturing data and documenting
                                     linkages between a patient's need/
                                     goal and relevant interventions in
                                     a standardized way and linked to
                                     relevant outcomes.
Care Coordination.................  Established continuity within the
                                     plan of care.
Care Coordination.................  Accessibility and functionality of
                                     plan of care.
Disease area dependent............  Measurement of adverse events that
                                     could be markers of poor care
                                     coordination.
Health and Well-Being.............  Episode-based cost measures for
                                     conditions of high prevalence and
                                     high cost.
Health and Well-Being.............  Improvement opportunities through
                                     standardized utilization measures.
Health and Well-Being.............  Comprehensive analysis of episode-
                                     based measures.
Health and Well-Being.............  Prioritize episode-based cost
                                     measures for conditions of high
                                     prevalence and high cost.
Health and Well-Being.............  Further development of measures of
                                     overuse and areas of resource use
                                     that are deemed inappropriate or
                                     wasteful, better integrate overuse
                                     and appropriateness measures into
                                     the domain of cost and resource
                                     use.
Health and Well-Being.............  Developed an accountability
                                     framework for how cost and resource
                                     use measures are designed and
                                     attributed based on the level of
                                     analysis.
Health and Well-Being.............  Developing measures that enhance
                                     cost transparency.
Health and Well-Being.............  Time driven activity-based costing
                                     (ABC), or micro-costing, approach
                                     should continue to be explored for
                                     measure development and potential
                                     evaluation for endorsement.
Health and Well-Being.............  Consumer out-of-pocket expenses.
Health and Well-Being.............  Actual prices paid by patients and
                                     health plans rather than measures
                                     using standardized pricing
                                     approaches.
Health and Well-Being.............  Trends in cost performance over time
                                     at the level of analysis of the
                                     health plan.
Health and Well-Being.............  Measures capturing systematic cost
                                     drivers.
Health and Well-Being.............  Cascading measures that roll up
                                     costs from all levels of analysis
                                     and which can be deconstructed to
                                     understand costs at lower levels of
                                     analysis.
Health and Well-Being.............  To understand efficiency, cost and
                                     resource use measures should be
                                     linked with:
                                     appropriateness/overuse
                                     measures
                                     outcome measures
                                     process measures
                                     clinical data and patient-
                                     reported outcomes.
Health and Well-Being.............  Measures capturing variations in
                                     cost and outcomes for potentially
                                     high cost patients (e.g.,
                                     cardiovascular or diabetes
                                     patients).
Health and Well-Being.............  Episode-based cost and resource use
                                     measures for high-impact conditions
                                     and procedures.
Health and Well-Being.............  Measures capturing actual prices
                                     paid to providers by health plans.
HEENT.............................  Measures for accountability and
                                     quality improvement that
                                     specifically address regionalized
                                     emergency medical care services
                                     such as:
                                     Boarding, defining
                                     appropriate boarding times.
                                     Crowding.
                                     Disaster preparedness, and
                                     Response.
HEENT.............................  Measurement related to facilities
                                     and coalitions or regions having a
                                     disaster plan in place.

[[Page 61024]]

 
HEENT.............................  Performance measures regarding the
                                     experience of both patients and
                                     their caregivers.
HEENT.............................  Social, economic, and environmental
                                     determinants of health.
HEENT.............................  Physical environment (e.g., built
                                     environments).
HEENT.............................  Policy (e.g., smoke-free zones).
Infectious Disease................  Specific subpopulations (e.g.,
                                     people with disabilities, elderly).
Infectious Disease................  Patient and population outcomes
                                     linked to improvement in functional
                                     status.
Infectious Disease................  Counseling for physical activity and
                                     nutrition in younger and middle-
                                     aged adults (18 to 65 years).
Infectious Disease................  Composites that assess population
                                     experience.
Infectious Disease................  Training, retraining, and
                                     development.
Infectious Disease................  Infrastructure to support the health
                                     workforce and to improve access.
Musculoskeletal...................  Retention and recruitment.
Musculoskeletal...................  Assessment of community and
                                     volunteer workforce.
Musculoskeletal...................  Experience (health workforce and
                                     person and family experience).
Musculoskeletal...................  Clinical, community, and cross
                                     disciplinary relationships.
Musculoskeletal...................  Workforce capacity and productivity.
Musculoskeletal...................  Workforce diversity and retention.
Neurology.........................  Leadership and accountability.
Neurology.........................  Addressing other populations with
                                     known disparities, e.g., gender,
                                     persons with disabilities, lesbian,
                                     gay, bisexual, and transgender
                                     (LGBT) population and correctional
                                     populations.
Neurology.........................  Health-related quality of life.
Neurology.........................  Inclusion of socioeconomic status
                                     variables within measure concepts,
                                     such as education level or income--
                                     particularly as proxies for health
                                     literacy/beliefs.
Neurology.........................  Tracking the flow of information
                                     specific to disparities and culture
                                     within healthcare through
                                     Accountable Care Organizations.
Neurology.........................  Identifying the number of bilingual/
                                     bicultural providers and tracking
                                     the number of qualified/certified
                                     medical interpreters and
                                     translators.
Neurology.........................  Measures using comparative analyses
                                     with a reference population (e.g.,
                                     percent adherence of a given
                                     measure with the targeted
                                     population as a numerator and the
                                     reference or majority population as
                                     the denominator with serial
                                     assessments to demonstrate
                                     improvement to unity).
Neurology.........................  Measurement of the effectiveness of
                                     services provided to the patient.
Neurology.........................  Measures related to effective
                                     engagement of diverse communities.
Neurology.........................  HPV vaccination catch-up for
                                     females--ages 19-26 years and--for
                                     males--ages 19-21 years.
Neurology.........................  Tdap/pertussis-containing vaccine
                                     for ages 19 + years.
Neurology.........................  Zoster vaccination for ages 60-64
                                     years.
Neurology.........................  Zoster vaccination for ages 65 +
                                     years (with caveats).
Neurology.........................  Composite including immunization
                                     with other preventive care services
                                     as recommended by age and gender.
Neurology.........................  Composite of Tdap and influenza
                                     vaccination for all pregnant women
                                     (including adolescents).
Neurology.........................  Composite including influenza,
                                     pneumococcal, and hepatitis B
                                     vaccination measures with diabetes
                                     care processes or outcomes for
                                     individuals with diabetes.
Neurology.........................  Composite including influenza,
                                     pneumococcal, and hepatitis B
                                     vaccinations measures with renal
                                     care measures for individuals with
                                     kidney failure/end-stage renal
                                     disease (ESRD).
Neurology.........................  Composite including Hepatitis A and
                                     B vaccinations for individuals with
                                     chronic liver disease.
Neurology.........................  Composite of all Advisory Committee
                                     on Immunization Practices of the
                                     Center for Disease Control and
                                     Prevention (ACIP/CDC) recommended
                                     vaccinations for healthcare
                                     personnel.
Neurology.........................  Outcome measures.
Neurology.........................  Antimicrobial stewardship.
Neurology.........................  HIV/AIDS:
                                     Testing for individuals 13-
                                     64 years of age
                                     Colposcopy screening for
                                     women living with HIV who have
                                     abnormal PAP smear tests
                                     Resistance testing for
                                     persons newly enrolled in HIV care
                                     with a viral load greater than
                                     1,000
                                     HIV screening at first
                                     prenatal care visit for all
                                     pregnant women
                                     Include stratification of
                                     disparity data.
Neurology.........................  Process and outcome measures to
                                     evaluate improvements in device
                                     associated infections in the
                                     hospital setting, particularly
                                     catheter-associated urinary tract
                                     infection.
Neurology.........................  Measures that include follow-up for
                                     screening tests.
Neurology.........................  Screening for sexually transmitted
                                     infections (STIs), including human
                                     papillomavirus (HPV).
Neurology.........................  Management of chronic pain.
Neurology.........................  Use of MRI for management of chronic
                                     knee pain.
Neurology.........................  Tendinopathy: Evaluation, treatment,
                                     and management.
Neurology.........................  Outcomes: Spinal fusion, knee and
                                     hip replacement.
Neurology.........................  Overutilization of procedures.
Neurology.........................  Secondary fracture prevention.
Neurology.........................  Measures that would drive improved
                                     diagnosis of Parkinson's disease.
Neurology.........................  Measures that include both
                                     assessment and referral, or
                                     assessment and treatment, for
                                     Parkinson's disease patients (e.g.,
                                     assessment and referral for rehab
                                     services).
Neurology.........................  Functional interventions or
                                     assessment measures for patients
                                     with dementia or Alzheimer's
                                     disease.
Neurology.........................  Assessment and referral for
                                     treatment and interventions for
                                     dementia/Alzheimer's disease.
Neurology.........................  Measures around support of
                                     caregivers of patients with
                                     dementia/Alzheimer's disease.
Neurology.........................  An outcome measure of getting people
                                     with dementia to stop driving.
Neurology.........................  Other organizations/areas to connect
                                     with around measurement (e.g.,
                                     working with the National Highway
                                     Traffic Safety Administration on
                                     safety measures around driving).
Neurology.........................  Measures that are more focused
                                     (e.g., measures focused on
                                     depression screening, rather than
                                     screening for all neuropsychiatric
                                     conditions).

[[Page 61025]]

 
Neurology.........................  Advance directives for dementia
                                     patients that are written early in
                                     the course of illness.
Neurology.........................  Broader definitions of which
                                     providers can meet a measure (e.g.,
                                     functional assessments/treatments
                                     should include physical and
                                     occupational therapists, not just
                                     physicians).
Neurology.........................  Interventions for women with
                                     epilepsy who might become pregnant.
Neurology.........................  A measure about the impact of
                                     pregnancy on the epilepsy
                                     treatment.
Neurology.........................  An outcome measure for epilepsy that
                                     focuses on seizure frequency.
Neurology.........................  Epilepsy measures that examine
                                     whether the treatment matches the
                                     epilepsy type and the seizure type.
Neurology.........................  Measures for epilepsy patients who
                                     are not seizure-free: Percent
                                     referred to an epilepsy specialist,
                                     percent referred for surgical
                                     evaluation.
Neurology.........................  Functional outcome measures for
                                     individuals with stroke, TBI, SCI,
                                     MS, PD, etc.
Neurology.........................  Patient reported measures in the
                                     areas of function, self-efficacy,
                                     balance/falls, knowledge of care
                                     (emergency care, red flags,
                                     medication, etc.)
Neurology.........................  A process measure of referral for
                                     formal driving assessment in
                                     patients with dementia/Alzheimer's
                                     Disease.
Neurology.........................  Reduction of psychotic symptoms in
                                     patients assessed with psychosis:
                                     Clinical trials have shown that
                                     psychotic symptoms can be reduced
                                     with appropriate management.
Palliative and End of Life Care...  Reduction of depression in patients
                                     assessed with depression or
                                     reduction of burden of depression
                                     in populations at risk for
                                     depression (e.g., Parkinson's
                                     disease).
Palliative and End of Life Care...  Frequency of falls/hip fracture in
                                     patients with a high falls risk
                                     (e.g., Parkinson's disease).
Person and Family Centered Care...  Measures of arterial/venous
                                     ulceration and plaque composition
                                     that are paired with measure #0507.
Person and Family Centered Care...  Measures of patients with indicators
                                     of dementia for other healthcare
                                     settings in addition to nursing
                                     homes (measures similar to #2091
                                     and #2092).
Person and Family Centered Care...  Measures around care plans for
                                     epilepsy.
Person and Family Centered Care...  Outcome measures for infants born to
                                     women with epilepsy (e.g., infants
                                     with congenital birth defects born
                                     to mothers who are on epilepsy
                                     medications).
Person and Family Centered Care...  Patient-reported outcome measures to
                                     assess the impact of the counseling
                                     about contraception and pregnancy
                                     for women with epilepsy.
Person and Family Centered Care...  Measures that incorporate screening
                                     for Mild Cognitive Impairment and
                                     dementia.
Person and Family Centered Care...  Measures around delirium,
                                     particularly for patients who have
                                     delirium superimposed on dementia.
Person and Family Centered Care...  Imaging: Measures that would impact
                                     care (e.g., how fast imaging is
                                     completed, how fast a reliable
                                     interpretation is completed,
                                     preliminary revisions to report;
                                     reports should capture a time
                                     window appropriate to stroke
                                     patients, contain guidelines about
                                     a minimum imaging study (e.g., CT
                                     vs. MRI in acute care), and be
                                     comprehensively-worded and
                                     accurate).
Pulmonary/Critical Care...........  End-of-life care in stroke.
Pulmonary/Critical Care...........  Palliative care (e.g., presence/
                                     absence of a palliative care
                                     consultation after stroke severity
                                     rating).
Pulmonary/Critical Care...........  Functional status outcome measures
                                     (especially functional status
                                     outcomes related to stroke
                                     severity).
Pulmonary/Critical Care...........  Measures with better information on
                                     exclusions, including exclusions
                                     weighted by stroke severity score
                                     and a way to validate patients
                                     excluded from reporting.
Pulmonary/Critical Care...........  Rehabilitation measures (both
                                     process and outcome, including
                                     whether patients actually receive
                                     rehabilitation services).
Pulmonary/Critical Care...........  Measures that explore hidden health
                                     disparities and/or disabilities and
                                     that focus on patients with health
                                     disparities and disabilities.
Pulmonary/Critical Care...........  Measures of pre-hospital care and
                                     emergency response, including use
                                     of stroke scale before hospital
                                     arrival and use of protocols by
                                     emergency response teams.
Pulmonary/Critical Care...........  Measures of post-acute care and
                                     rehabilitation care (prescription
                                     use at timed intervals after
                                     stroke, whether health problems are
                                     controlled over time, etc.)
Pulmonary/Critical Care...........  Transfers between facilities.
Pulmonary/Critical Care...........  Community-level measures that
                                     capture whether or not a patient
                                     received services ordered (such as
                                     t-PA and rehabilitation or if/how
                                     code protocols exist and if they
                                     are followed).
Pulmonary/Critical Care...........  Hospital-level dysphagia screening
                                     measure.
Pulmonary/Critical Care...........  Measures of care separated by stroke
                                     vs. TIA; specific measures for the
                                     care of TIA patients.
Pulmonary/Critical Care...........  Screening and diagnosis of atrial
                                     fibrillation, including identifying
                                     appropriate patients, screening
                                     rates, rate of actual detections/
                                     under-diagnosis rate, and use of
                                     types of diagnostic tools used to
                                     determine atrial fibrillation.
Pulmonary/Critical Care...........  An outcome measure that is a
                                     combined endpoint of death and
                                     severe disability (i.e., Rankin
                                     Score 4-6), for a patient-centered
                                     approach that would incorporate a
                                     patient's values on quality of
                                     life.
Pulmonary/Critical Care...........  Measures to document patient and
                                     family training and education in
                                     acute and post-acute settings to
                                     reduce disability, burden of care,
                                     and primary and secondary
                                     prevention.
Readmissions......................  Overuse.
Readmissions......................  Appropriateness.
Resource Use......................  Patient safety.
Resource Use......................  Effectiveness (linking cost &
                                     quality).
Resource Use......................  Trauma.
Resource Use......................  Disparities.
Resource Use......................  Vascular screening for patients with
                                     existing leg ulcers.
Resource Use......................  Adequate venous compression for
                                     patients with existing venous leg
                                     ulcers.
Resource Use......................  Adequate offloading patients with
                                     diabetic foot ulcers.
Resource Use......................  Adequate support surface for
                                     patients with stage III-IV pressure
                                     ulcers.
Resource Use......................  Induction and augmentation of labor.
Resource Use......................  Outcomes of neonatal birth injury.
Resource Use......................  Clostridium difficile colitis is
                                     epidemic in U.S. and should be
                                     measured.
Resource Use......................  Vascular catheter infections in
                                     other settings including, dialysis
                                     catheters, home infusion,
                                     peripherally inserted central
                                     catheter lines, nursing home
                                     catheters.
Resource Use......................  Monitoring of product related
                                     events.

[[Page 61026]]

 
Resource Use......................  EHR programming related errors.
Resource Use......................  The expectation for physical
                                     mobility among hospitalized adults:
Resource Use......................  Measures that extend to settings
                                     outside the hospital, such as post-
                                     acute care and extended care
                                     facilities, specifically nursing
                                     homes.
Resource Use......................  Measures that focus on best
                                     practices of health care delivery,
                                     specifically interventions that
                                     have been shown to result in
                                     improved outcomes.
Resource Use......................  Measures that stratify by direct
                                     patient care nursing hours and non-
                                     direct patient care nursing hours.
Safety............................  Longer term follow-up of patients is
                                     needed to determine the effects of
                                     care and interventions as opposed
                                     to only focusing on shorter-term
                                     outcomes.
Safety............................  Voluntary patient surveys should be
                                     used more to evaluate the care
                                     patients received related to
                                     treatment and follow-up.
Safety............................  Organizational measures that examine
                                     the culture of patient safety.
Safety............................  Outcome measures that examine social
                                     factors in the prevention and
                                     treatment of falls, focusing on
                                     community level measurement.
Safety............................  Measures that address the continuum
                                     of care including patient
                                     assessment, plan of care,
                                     intervention, and outcomes, and
                                     should take into account care
                                     across various settings, such as
                                     inpatient, outpatient, ambulatory
                                     surgical centers, and home health.
Safety............................  Measures that focus on complications
                                     linked to surgical site infections
                                     (including cesarean sections) and
                                     outcomes.
Safety............................  Measures that are easy to understand
                                     and meaningful to consumers.
Safety............................  Measures focused on in-hospital,
                                     severity adjusted, high mortality
                                     conditions such as 30-day mortality
                                     rates, readmissions, sepsis and
                                     acute respiratory distress syndrome
                                     (ARDS).
Safety............................  Measures for earlier identification
                                     of sepsis at the compensated stage
                                     before it becomes decompensated
                                     septic shock and appropriate
                                     resuscitative measures.
Safety............................  Measures of efficiency and
                                     overutilization.
Safety............................  Measures that focus on palliative
                                     care for patients with end-stage
                                     pulmonary conditions.
Safety............................  Better measures of comprehensive
                                     asthma education, e.g., instruction
                                     related to the appropriate
                                     application of handheld inhalers
                                     prior to discharge and
                                     demonstration of use.
Safety............................  Measures of unplanned pediatric
                                     extubations.
Safety............................  Measures for effectiveness and
                                     outcomes of post-acute care for
                                     COPD patients.
Safety............................  Measures of functional status.
Safety............................  Measures for quality of spirometries
                                     in relation to meeting the American
                                     Thoracic Society (ATS) standards
                                     for pediatric and adult patients.
Safety............................  More outpatient composite measures
                                     targeted for consumer use.
Safety............................  Management of sepsis.
Safety............................  Overuse of blood transfusions.
Safety............................  Ventilator-associated pneumonia and
                                     mechanical ventilation.
Safety............................  Risk-adjusted ICU outcome.
Safety............................  Therapeutic hypothermia.
Safety............................  Daily chest radiographs in ICU
                                     patients.
Safety............................  Screening of ALI/ARDS.
Safety............................  COPD.
Safety............................  Palliative care and dyspnea.
Safety............................  Asthma.
Safety............................  Idiopathic pulmonary fibrosis.
Safety............................  Iatrogenic pneumothorax with
                                     thoracentesis.
Safety............................  Measure gaps for the pediatric
                                     population (related to admissions/
                                     readmissions).
Safety............................  Complications.
Safety............................  All-cause readmissions.
Safety............................  Mortality.
Surgery...........................  Orthopedic surgery, bariatric
                                     surgery (measures of patient weight
                                     loss and maintenance of that weight
                                     loss over time), neurosurgery, and
                                     others.
Surgery...........................  Measures of adverse outcomes that
                                     are structured as ``days since last
                                     event'' or ``days between events''.
Surgery...........................  Measures around functional status or
                                     return to function after surgery,
                                     as well as other patient-centered
                                     and patient-reported outcomes like
                                     patient experience.
------------------------------------------------------------------------

III. Secretarial Comments on the 2016 Annual Report to Congress and the 
Secretary

    Once again we thank the National Quality Forum (NQF) and the many 
stakeholders who participate in NQF projects for helping to advance the 
science and utility of health care quality measurement. As part of its 
annual recurring work to maintain a strong portfolio of endorsed 
measures for use across varied providers, settings of care, and health 
conditions, NQF reports that in 2015 it updated its portfolio of 
approximately 600 endorsed measures by reviewing and endorsing or re-
endorsing 161 measures and removing 42. Removed measures no longer met 
endorsement criteria, were retired by their developers, were replaced 
by stronger measures, or were no longer needed because providers 
consistently performed at the highest level on these measures. NQF-
endorsed measures address a wide range of health care topics relevant 
to HHS programs including such high prevalence and high impact 
conditions and topics as: Person- and family-centered care, care 
coordination, palliative and end-of-life care, cardiovascular disease, 
behavioral health, pulmonary/critical care, neurology, perinatal care, 
and cancer. Additionally, as part of its annual review of measures 
proposed for use in the Medicare program, NQF stakeholder teams 
reviewed and made recommendations on nearly 200 measures for use in 20 
different programs, including measures under consideration to implement 
new post-acute care measurement requirements

[[Page 61027]]

mandated by the Improving Medicare Post-Acute Care Transformation 
(IMPACT) Act of 2014. In doing all of this work, NQF teams identified 
more than 250 measurement gaps needing attention from measure 
developers and those who use quality measures.
    In addition to this important recurring work, a number of NQF's 
2015 projects tackled or began tackling several difficult quality 
measurement issues that are key to the successful implementation of new 
patient care models and the transformation of the health care delivery 
system overall. These projects address:
     How to ``attribute'' patient health care and outcomes to 
individual providers under newer payment models in which multiple 
providers are involved in delivering care;
     How to address the performance measurement challenges of 
geographic isolation and small practice size common to rural and other 
low-volume providers;
     How to detect and assess new types of health care errors 
as we increasingly rely on health information technology (Health IT) to 
reform health care; and
     How to address patient social risk factors when measuring 
healthcare quality and outcomes.
    ``Attribution'' is a method used to assign patients and their 
quality outcomes to specific providers when trying to evaluate patient 
care. As HHS works to develop new models of care delivery and 
alternative payment models that integrate and coordinate care delivered 
by multiple providers, attributing the quality of health care delivered 
and the outcomes of that care to a particular provider or providers 
becomes more difficult. This issue has become increasingly important as 
these new models of care delivery often are built on an expectation of 
shared accountability--across primary care physicians, specialist 
physicians, physician groups, nurse practitioners, and the full 
healthcare team. In 2015 HHS requested NQF to convene a multi-
stakeholder committee to examine this topic and recommend principles to 
guide the selection and implementation of approaches to attribution, 
potential approaches to validly and reliably attribute performance 
measurement results to one or more providers under different delivery 
models, and models of attribution for testing. Although this work just 
began in late 2015, HHS is closely following it and eager to receive 
the recommendations of this committee.
    NQF's report on ``Performance Measurement for Rural Low-Volume 
Providers'' similarly was commissioned by HHS' Health Resources and 
Services Administration (HRSA) to identify challenges in healthcare 
performance measurement faced by rural providers and to make 
recommendations to address these, particularly in the context of 
Medicare pay-for-performance programs. This report aimed to support 
Critical Access Hospitals (CAHs), Rural Health Clinics, Community 
Health Centers, small rural non-CAH hospitals, other small rural 
clinical practices, and the clinicians who serve in any of these 
settings.
    The resulting NQF report well-articulated the challenges these 
providers face, including the geographic isolation of some rural 
providers and the concomitant lack of patient transportation and 
provider information technology capabilities. These rural providers 
also may not have enough patients to achieve reliable and valid 
performance measurement results for all measures. Because of these 
``small number'' challenges and because rural providers sometimes are 
paid differently than other providers, many HHS quality initiatives 
have historically excluded them from participation. We recognize that 
this can have the unintended effects of preventing rural residents from 
having access to information on provider performance, and preventing 
these rural providers from earning payment incentives that are open to 
non-rural providers.
    To address these challenges, the stakeholders convened by NQF 
recommended phasing in rural providers' participation in quality 
measurement and quality improvement programs, and a number of specific 
approaches to measure development, alignment, selection and rural 
provider participation in pay-for-performance programs to support this 
transition. In response, HRSA, CMS, and HHS' Office of the Assistant 
Secretary for Planning and Evaluation are working together to examine 
how best to act on these recommendations.
    The effective deployment of Health IT such as electronic health 
records (EHRs) is another critical dimension of reforming the delivery 
of health care. Health IT and health information exchange play a 
critical role in the continuing evolution of delivery system reform. As 
evidence of this, the new Merit-based Incentive Payment System (MIPS) 
for payments to physicians and other clinicians created by the Medicare 
Access and CHIP Reauthorization Act of 2015 (MACRA) specified Advancing 
Care Information (referred to in the statute as meaningful use of 
certified EHR technology) as one of four performance categories upon 
which payment adjustments will be based. Approximately 98% of hospitals 
and more than 80% of physicians currently use EHRs to help provide 
better patient care.
    While promoting and assisting providers to adopt this new 
technology, HHS is mindful that the use of new technology of all kinds 
can be accompanied by unintended consequences and the potential risk of 
new types of errors. With respect to health IT, for example, the NQF 
HIT Safety Committee found that health IT user interfaces have 
sometimes proven to be unclear, confusing, cumbersome, or time-
consuming for clinicians to use, leading to inadvertent mistakes in 
data entry or retrieval of information, and other opportunities for 
error. Conversely, HHS recognizes that there are opportunities for this 
new technology to eliminate or reduce the occurrence of a variety of 
adverse events. For this reason, HHS' Office of the National 
Coordinator for Health Information Technology (ONC) requested NQF to 
examine the intersection of Health IT and patient safety; identify 
priority measurement areas with the greatest potential for both 
improving the safety of Health IT and using Health IT to improve 
patient safety; make recommendations on how to address identified gaps 
and challenges in Health IT safety measurement; and identify best-
practices for the measurement of Health IT safety issues. Although the 
report of this work was not released until early 2016, the majority of 
this work was conducted in 2015. The final report was very helpful to 
ONC and HHS overall, and ONC is working with AHRQ and CMS to 
incorporate the Health IT safety measure framework and measure concepts 
into measurement strategies.
    Finally, we note that in 2015, NQF began a two year trial period 
during which new measures submitted for endorsement and endorsed 
measures that are undergoing maintenance review would be reviewed for 
possible ``risk adjustment'' for socioeconomic status (SES) and other 
demographic factors. Risk adjustment is a statistical technique that 
allows certain factors to be taken into account when computing and 
making comparisons between different performers. Although it has been 
common to ``risk adjust'' health care provider performance measures 
based on certain patient health factors such as how ill or how old 
patients are, it is been debated for some time whether performance 
measures should be adjusted for factors other than a patients' 
illness--such as a patient's race, ethnicity, income or where they 
live. If populations with SES risk factors

[[Page 61028]]

(social risk) suffer worse health outcomes and have higher costs due to 
factors beyond providers' control, not adjusting for these differences 
could unfairly penalize providers. On the other hand, incorporating 
social risk factors into payment could mask low quality care. This 
issue is particularly complex because research evidence suggests that 
both of these forces often contribute to the outcomes experienced by 
patients in various communities.
    This issue is now being studied by HHS' Office of the Assistant 
Secretary for Planning and Evaluation (ASPE) as mandated by the 
Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. 
Through the IMPACT Act, Congress mandated ASPE to conduct two studies 
evaluating the effect of social risk factors on quality measures used 
in Medicare quality and payment programs. The results of this first 
ASPE study should be of great help to NQF as it undertakes this trial 
period.
    In conclusion, the need for quality measurement to evolve alongside 
healthcare delivery reform is evident in many of the targeted projects 
that NQF is being asked to undertake. HHS greatly appreciates the 
ability to bring many and diverse stakeholders to the table to help 
develop the strongest possible approaches to quality measurement as a 
key component to health care delivery system reform. We look forward to 
continued strong partnership with the National Quality Forum in this 
ongoing endeavor.

IV. 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: August 25, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.

\i\ Throughout this report, the relevant statutory language appears 
in italicized text.
\ii\ Department of Health and Human Services (HHS). Report to 
Congress: National Strategy for Quality Improvement in Health Care. 
Washington, DC: HHS; 2011. Available at http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf. Last accessed February 
2016.
\iii\ NQF steering committees are comparable to the expert advisory 
committees typically convened by federal agencies.
\iv\ HHS. Report to Congress: National Strategy for Quality 
Improvement in Health Care. Washington, DC: HHS; 2011. Available at 
http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf. Last 
accessed February 2016.
\v\ National Quality Forum (NQF). Multistakeholder Input on a 
National Priority: Improving Population Health by Working with 
Communities--Action Guide 2.0. Washington, DC: NQF: 2015. Available 
at http://www.qualityforum.org/Publications/2015/07/Population_Health_Framework_-_Phase_2_-_Action_Guide_2_0.aspx. Last 
accessed February 2016.
\vi\ Commission on Long-Term Care. Report to the Congress. 
Washington, DC: Government Printing Office (GPO); 2013. Available at 
http://www.gpo.gov/fdsys/pkg/GPO-LTCCOMMISSION/pdf/GPO-LTCCOMMISSION.pdf. Last accessed February 2016.
\vii\ NQF. Addressing Performance Measurement Gaps in Home and 
Community Based Services to Support Community Living: Initial 
Components of the Conceptual Framework. Interim Report. Washington, 
DC: NQF; 2015. Available at http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=79920. Last accessed February 
2016.
\viii\ NQF. Performance Measurement for Rural Low-Volume Providers. 
Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/09/Rural_Health_Final_Report.aspx. Last accessed 
February 2016.
\ix\ Weiner JP, Kfuri T, Fowles JB. ``E-iatrogenesis'': The most 
critical unintended consequence of CPOE and other HIT. J Am Med 
Inform Assoc. 2007;14(3):387-388.
\x\ NQF steering committees are comparable to the expert advisory 
committees typically convened by federal agencies.
\xi\ NQF. Measure Evaluation Criteria and Guidance for Evaluating 
Measures for Endorsement. Washington, DC: NQF; 2015. Available at 
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=79434. Last accessed February 
2016.
\xii\ Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, 
and comorbidity of twelve-month DSM-IV disorders in the National 
Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 
2005;62(6):617-627.
\xiii\ Kilbourne A, Keyser D, Pincus H. Challenges and opportunities 
in measuring the quality of mental health care. Can J Psychiatry. 
2010; 55(9):549-557.
\xiv\ Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, 
and comorbidity of twelve-month DSM-IV disorders in the National 
Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 2005; 
62(6):617-627.
\xv\ Mark TL, Levit KR, Vandivort-Warren R, et al. Changes in US 
spending on mental health and substance abuse treatment, 1986-2005, 
and implications for policy. Health Aff (Millwood). 2011; 30(2):284-
292.
\xvi\ NQF. Behavioral Health Endorsement Maintenance 2014: Phase 3. 
Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspx. Last accessed February 2016.
\xvii\ NQF. Endorsing Cost and Resource Use Measures: Phase 2. 
Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/02/Endorsing_Cost_and_Resource_Use_Measures_Phase_2.aspx. Last accessed 
February 2016.
\xviii\ NQF. Endorsing Cost and Resource Use Measures: Phase 3 Final 
Technical Report. Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/02/Cost_and_Resource_Use_-_Phase_3_Final_Report.aspx. Last accessed February 2016.
\xix\ NQF. NQF-Endorsed Measures for Endocrine Conditions, 2013-
2015. Final Report. Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/11/NQF-Endorsed_Measures_for_Endocrine_Conditions_Final_Report.aspx. Last 
accessed February 2016.
\xx\ NQF. NQF-Endorsed Measures for Musculoskeletal Conditions 
Technical Report. Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/01/NQF-Endorsed_Measures_for_Musculoskeletal_Conditions.aspx. Last accessed 
February 2016.
\xxi\ Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and 
Stroke Statistics--2010 Update. A Report from the American Heart 
Association Statistics Committee and Stroke Statistics Subcommittee. 
Circulation. 2010;121:e1-e170.
\xxii\ NQF. NQF-Endorsed Measures for Cardiovascular Conditions 
2014-2015: Phase 2. Final Report. Washington, DC: NQF; 2015. 
Available at http://www.qualityforum.org/Publications/2015/08/NQF-Endorsed_Measures_for_Cardiovascular_Conditions_2014-2015_-_Phase_2.aspx. Last accessed February 2016.
\xxiii\ Dartmouth Atlas Project, PerryUndem Research & 
Communications. The Revolving Door: A Report on U.S. Hospital 
Readmissions. Princeton, NJ: Robert Wood Johnson Foundation; 2013. 
Available at http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/02/the-revolving-door-a-report-on-u-s-hospital-readmissions.html.
\xxiv\ Medicare Payment Advisory Committee (MEDPAC). Report to the 
Congress: Medicare and the Health Care Delivery System. Washington, 
DC: MedPAC; 2013. Available at http://www.medpac.gov/documents/reports/jun13_entirereport.pdf.
\xxv\ NQF. All-Cause Admissions and Readmissions Measures Final 
Report. Washington, DC: NQF; 2015. Available at http://
www.qualityforum.org/

[[Page 61029]]

Publications/2015/04/All-
Cause_Admissions_and_Readmissions_Measures_-_Final_Report.aspx. Last 
accessed February 2016.
\xxvi\ NQF. NQF-Endorsed Measures for Patient Safety Final Report. 
Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/01/NQF-Endorsed_Measures_for_Patient_Safety,_Final_Report.aspx. Last 
accessed February 2016.
\xxvii\ NQF. NQF-Endorsed Measures for Person- and Family-Centered 
Care Phase 1 Technical Report. Available at http://www.qualityforum.org/Publications/2015/03/Person-_and_Family-Centered_Care_Final_Report_-_Phase_1.aspx. Last accessed February 
2016.
\xxviii\ Centers for Disease Control and Prevention (CDC). National 
Hospital Discharge Survey: 2010 Table. Procedures by Selected 
Patient Characteristics--Number by Procedure Category and Age. 
Atlanta, GA: CDC; 2010. Available at http://www.cdc.gov/nchs/nhds/nhds_tables.htm.
\xxix\ Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the 
United States, 2006. Natl Health Stat Report. 2009;(11):1-25. 
Available at http://www.cdc.gov/nchs/data/nhsr/nhsr011.pdf. Last 
accessed February 2016.
\xxx\ Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the 
United States, 2006. Natl Health Stat Report. 2009;(11):1-25. 
Available at http://www.cdc.gov/nchs/data/nhsr/nhsr011.pdf. Last 
accessed February 2016.
\xxxi\ NQF. NQF-Endorsed Measures for Surgical Procedures Technical 
Report. Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/02/NQF-Endorsed_Measures_for_Surgical_Procedures.aspx. Last accessed 
February 2016.
\xxxii\ NQF. NQF-Endorsed Measures for Surgical Procedures, 2015 
Final Report. Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/12/Surgery_2014_Final_Report.aspx. Last accessed February 2016.
\xxxiii\ NQF. NQF-Endorsed Measures for Renal Conditions, 2015 
Technical Report. Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/12/Renal_Measures_Final_Report.aspx. Last accessed February 2016.
\xxxiv\ National Partnership for Women & Families. Transforming 
maternity care. United States maternity care facts and figures Web 
site. http://transform.childbirthconnection.org/resources/datacenter/factsandfigures/. Last accessed February 2016.
\xxxv\ Save the Children. State of the World's Mothers 2015 Report: 
The Urban Disadvantage. Fairfield, CT: Save the Children; 2015. 
Available at https://www.savethechildren.net/state-worlds-mothers-2015. Last accessed February 2016.
\xxxvi\ American Cancer Society (ACS). Cancer Facts & Figures 2015. 
Atlanta, GA: ACS; 2015. Available at http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. Last 
accessed February 2016.
\xxxvii\ Soni A. Trends in use and expenditures for cancer treatment 
among adults 18 and older, U.S. civilian noninstitutionalized 
population, 2001 and 2011. Rockville, MD: Agency for Healthcare 
Research and Quality (AHRQ); 2014. Statistical Brief #443. Available 
at http://meps.ahrq.gov/mepsweb/data_files/publications/st443/stat443.pdf. Last accessed February 2016.
\xxxviii\ Soni A. Trends in use and expenditures for cancer 
treatment among adults 18 and older, U.S. civilian 
noninstitutionalized population, 2001 and 2011. Rockville, MD: 
Agency for Healthcare Research and Quality (AHRQ); 2014. Statistical 
Brief #443. Available at http://meps.ahrq.gov/mepsweb/data_files/publications/st443/stat443.pdf. Last accessed February 2016.
\xxxix\ Buying Value. Driving progress on core measures for value-
purchasing Web site. http://www.buyingvalue.org/. Last accessed June 
2015.
\xl\ NQF. Strengthening the Core Set of Healthcare Quality Measures 
for Adults Enrolled in Medicaid. Washington, DC: NQF; 2015 Available 
at http://www.qualityforum.org/Publications/2015/08/Strengthening_the_Core_Set_of_Healthcare_Quality_Measures_for_Adults_Enrolled_in_Medicaid,_2015.aspx. Last accessed February 2016.
\xli\ NQF. Strengthening the Core Set of Healthcare Quality Measures 
for Children. Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/08/Strengthening_the_Core_Set_of_Healthcare_Quality_Measures_for_Children_Enrolled_in_Medicaid,_2015.aspx. Last Accessed February 2016.
\xlii\ NQF. Dual Eligible Beneficiary Interim Report. Washington, 
DC: NQF, 2012 Available at http://www.qualityforum.org/Publications/2012/12/Dual_Eligible_Beneficiary_Population_Interim_Report_2012.aspx. Last 
accessed February 2016.
\xliii\ NQF. Performance Measurement for Rural Low-Volume Providers. 
Washington, DC: NQF; 2015. Available at http://www.qualityforum.org/Publications/2015/09/Rural_Health_Final_Report.aspx. Last accessed 
February 2016.
\xliv\ Conway PH. Core Quality Measures Collaborative Working Group. 
The Core Quality Measures Collaborative: A rationale and framework 
for public-private quality measure alignment. Health Affairs Blog. 
June 23, 2015. http://healthaffairs.org/blog/2015/06/23/the-core-quality-measures-collaborative-a-rationale-and-framework-for-public-private-quality-measure-alignment/. Last accessed February 2016.

[FR Doc. 2016-20908 Filed 9-1-16; 8:45 am]
 BILLING CODE 4150-05-P