NQF-Commissioned RAND Report Points Way to Using Health Performance Measures to Support Innovative Payment Reforms 

Washington, DC – A first-of-its-kind RAND report commissioned by the National Quality Forum (NQF) provides important direction for achieving payment reforms designed to improve healthcare quality. Based on a thorough review of 90 different payment models planned or in place across the nation, the report identifies uses of available performance measures for 11 payment reform models, as well as five key areas where new measures are needed to support payment reforms that reward value over volume.

With support from the Robert Wood Johnson Foundation, NQF commissioned this groundbreaking research to consider the types of measures needed to support innovative payment reforms. “Commissioning the RAND research into measures to support payment reform is one of many ways NQF is proactively working to respond to current and emerging needs,” said Janet Corrigan, PhD, MBA, president and CEO of the National Quality Forum. “In addition, NQF is convening a partnership of stakeholders, including consumer representatives, from across the healthcare arena to help identify the right measures for payment reform approaches.”

Because the most common fee-for-service payment methods can perpetuate unnecessary care, new initiatives that pay for healthcare in ways that improve quality are increasing in this country. The new payment models vary from withholding payment for avoidable errors to paying bonuses for better results. Performance measures play a key role in paying for better care and detecting potential harms that could arise through cost cutting.

“In an environment that emphasizes more value for every healthcare dollar, refinements in measurement are key to successful payment reform,” said Thomas Valuck, MD, JD, NQF’s senior vice president of strategic partnerships. “These measures will be important in not only ensuring that payment rewards the right care, but also in preventing unintended consequences that could result from hand picking the healthiest patients to achieve a higher payment.”

“Employers want to tie more and more of the payments to healthcare providers to the quality and efficiency of the care they deliver,” added Suzanne F. Delbanco, PhD, executive director of Catalyst for Payment Reform, an independent organization led by large employers, with active involvement of providers, health plans, consumers, and labor groups working to improve quality and reduce costs by identifying and coordinating workable solutions to improve how we pay for healthcare in the United States. “This study charts the path for building out the measures employers need to achieve paying for value instead of volume.”

To date, more than 600 NQF-endorsed® healthcare performance measures are in use across the nation, but the number applicable to any given setting or clinical area is far more limited. Some measures focus on specific steps in providing care, such as whether heart attack patients receive necessary prescriptions. Other measures use a wide-angle lens to look at results—for example, whether patients sent home from the hospital have improved health or end up returning with complications that could have been avoided. Each tool provides a different view, assessing performance from a specific angle.

According to the RAND report, the following types of measures will be the key to payment reforms aimed at improving healthcare and achieving better health for individuals and communities:

• outcome measures that focus on patient results—from avoidable harms to improved health;
• care coordination measures that capture appropriate patient follow-up care needed to keep patients on track to improved health;
• patient engagement measures to assess whether care empowers patients and their caregivers to improve health;
• organizational capability measures that assess whether new systems (accountable care organizations and medical homes) are sufficient to deliver high-quality care;
• composite measures that combine the results of individual measures into an overall indicator of quality, allowing for a more comprehensive assessment of the care delivered to patients;
• efficiency measures that combine quality and resource use measures; and
• disparity measures that ensure efforts to cut costs don’t lead to favoring certain types of patients.

“These findings should signal those who develop measures, and the sponsors who invest in this work, to focus on the kinds of measures needed to ensure that payment reforms achieve their intended goal of improving care and reducing costs,” said RAND’s Eric Schneider MD, MSc, FACP, principal author of the report.

The NQF portfolio includes measures in each of these areas, but there are important gaps in available measures and limitations in the ability to generate measure results. For example, about one-fourth of currently endorsed measures assess outcomes of care, but these tend to focus on outcomes proximate to a healthcare encounter (e.g., hospital mortality), not long-term outcomes (e.g., three-year cancer survival). NQF has also identified 35 “disparity-sensitive” measures that focus on areas where there are known disparities in the care, but data on race, ethnicity, and language are not systematically collected in many healthcare settings. Measures of patient engagement are few in number, and significant resources will need to be invested in measure development and testing to fill this gap.

Over the past 10 years, NQF-endorsed measures have become a common point of reference for those who provide, receive, and pay for healthcare. NQF endorsement starts when measure developers, such as the National Committee for Quality Assurance, the Physician Consortium for Performance Improvement convened by the American Medical Association, The Joint Commission, and others submit proposed measures to NQF for review. NQF convenes steering committees composed of diverse stakeholders across the healthcare field, from patient to provider to payer, to consider each measure’s importance, validity, and usefulness.

Access the full report. 

NQF operates under a three-part mission to improve the quality of American healthcare by: 

• Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them; 
• Endorsing national consensus standards for measuring and publicly reporting on performance; and 
• Promoting the attainment of national goals through education and outreach programs.