An Overview of NQF Endorsement and MAPSamuel Stolpe, PharmD, MPHNQF Senior Director, Quality Measurement
http://www.qualityforum.org
August 21, 2020
Agenda
Endorsement Overview
Measure Applications Partnership Overview
Questions
2
Endorsement Overview
3
NQF Measure Endorsement
Multi‐stakeholder participation is foundational to NQF
NQF has been endorsing measures since 2001 “NQF‐endorsed measure” is a the gold standard for quality NQF awarded contract by HHS as the “consensus‐based entity” designated in federal statute for endorsement activities
All 400+ NQF‐endorsed measures are in included in Quality Positioning System
Endorsement via the Consensus Development Process (CDP)
Consensus depends on participation and feedback from members and stakeholders
Over the years, the CDP has been revised, always encouraging more feedback from members and stakeholders
4
Major Endorsement Criteria Importance to measure and report
Greatest potential of driving improvements; if not important, the other criteria are less meaningful (must‐pass)
Reliability and Validity‐scientific acceptability of measure properties Goal is to make valid conclusions about quality; if not reliable and valid, there is risk of improper interpretation (must‐pass)
Feasibility As little burden as possible; if not feasible, consider alternative approaches
Usability and Use (must‐pass for maintenance measures) Use for accountability and improvement; if not useful, probably do not care if feasible
Comparison to related or competing measures 5
CDP – 6 Steps for Measure Endorsement
Intent to Submit
Call for Nominations
Measure Evaluation
Public Commenting Period with Member Support
Measure Endorsement Scientific Methods Panel CDP Standing Committee Consensus Standards Approval Committee (CSAC)
Measure Appeals
6
Measure Review: Two Cycles Per Year
7
NQF Endorsement Committees
Behavioral Health and
Substance Use
Renal
Patient Safety Neurology
Cardiovascular
Patient Experience and
Function
Primary Care and Chronic
Illness
All‐Cause Admissions
and Readmissions
Perinatal and Women’s Health
Geriatrics and Palliative Care
Surgery
Cost & Efficiency
8
Committee Measure Evaluation Process
Preliminary Analysis (PA) The PA will be used as a starting point for the Committee discussion and evaluation
Methods Panel will complete review of Scientific Acceptability criterion for complex measures
Committee Review Each measure discussed criterion by criterion Votes made using structured evaluation and voting process
9
Measure Applications Partnership Overview
10
Background
The Patient Protection and Affordable Care Act of 2010
Measure Applications Partnership Convened by NQF since 2011 Multistakeholder entity
Provide recommendations on measures under consideration for use in federal quality programs by HHS HHS publishes a list of measures under consideration (MUC) for rulemaking by December 1 of each year
MAP provides input to HHS on those measures by February 1 of the following year
11
Pre‐Rulemaking
CMS Selects MUC
MAP recommends
CMS considers MAP input
12
Inputs
• National and CMS Quality Strategies• Legislative Mandates• Public and Stakeholder Comments• Measure Monitoring and Maintenance• National Impact Assessment and Other Reports
Proposed & Final Rules
Rules Deployed
Quality Measures Developed
Measure Priorities Planning
https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/MMS/Pre‐Rulemaking‐MUC.html
MAP Structure
13
MAP Federal Programs
14
MAP Hospital Workgroup Programs
15
End‐Stage Renal Disease (ESRD) QIP
PPS‐Exempt Cancer Hospital Quality Reporting
(PCHQR)
Ambulatory Surgical Center Quality Reporting
(ASCQR)
Inpatient Psychiatric Facility Quality Reporting
(IPFQR)
Hospital Outpatient Quality Reporting (HOQR)
Hospital Inpatient Quality Reporting (IQR)
Hospital Value‐Based Purchasing (VBP)
Hospital Readmissions Reduction Program (HRRP)
Hospital‐Acquired Conditions Reduction Program (HACRP)
MAP Clinician Workgroup Programs
16
Merit‐based Incentive Payment System (MIPS)
Medicare Shared Savings Program
(SSP)
Medicare Part C and D Star Ratings
MAP PAC‐LTC Workgroup Programs
17
Skilled Nursing Facility Value‐Based
Purchasing Program (SNF VBP)
Skilled Nursing Facility Quality Reporting Program (SNF QRP)
Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP)
Long‐Term Care Hospital Quality
Reporting Program (LTCH QRP)
Hospice Quality Reporting Program
(HQRP)
Home Health Quality Reporting Program
(HH QRP)
MAP Members
Organizational• Constitute the majority of MAP members
• Include those that are interested in or affected by the use of measures
• Organizations designate reps
Subject Matter Experts• Serve as individual representatives bringing topic‐specific knowledge to MAP deliberations
• Co‐chairs of MAP’s Coordinating Committee, workgroups, and task forces are SMEs
Federal Liaisons • Serve as ex‐officio, nonvoting members representing a federal agency
18
Public Comment Opportunities
Nominations – proposed rosters July 24 Comments help ensure balanced stakeholder perspective
MUC list release – posted by Dec. 1, closes Dec. 8 Comments are sent to Workgroups for their consideration
MAP Workgroups in‐person meeting – second week of December Opportunity for public commenting during in‐person meetings
MAP Workgroups MUC recommendations – Dec. 23 – Jan. 11 NQF releases both a report and spreadsheet with results and rationale for workgroup recommendations
Comments are sent to Coordinating Committee for its consideration
MAP Coordinating Committee in‐person meeting – January 19 Opportunity for public commenting during in‐person meeting
19
Questions?
20
THANK YOU.
NATIONAL QUALITY FORUMhttp://www.qualityforum.org
21