NQF Begins Accepting Public Comments to Review Quality Measures Used in Federal Programs 

Washington, DC – Today, the National Quality Forum (NQF) launched a seven-day public comment period to solicit input on measures to consider removing from federal quality reporting and performance-based payment programs. First piloted in the 2021-2022 cycle, the Centers for Medicare & Medicaid Services (CMS) initiated Measure Set Review (MSR) to offer a holistic review of quality measures with input from the Measure Applications Partnership’s (MAP) diverse stakeholders. MSR builds on and balances the MAP’s long-standing role of considering which measures to add to federal programs by now also considering which measures to remove.

Members of MAP have identified MSR as a strategic opportunity to step back from individual measure scrutiny to broadly look at the role of quality measurement and programs in achieving desired health outcomes.

“Conducting a thoughtful review of performance measures used in federal programs is an essential discipline to continuously improving the quality, safety and outcomes of care experienced across the nation. Using MAP’s multistakeholder consensus process to recommend both the addition and removal of measures promotes parsimony and impact across federal performance improvement programs. We are excited to build on the insights from the 2021 pilot as we continue to partner with CMS on expanding this novel component of the work,” said Dana Gelb Safran, ScD, President & CEO, NQF.

The 2022 MSR process is divided into four overarching steps: prioritize, survey, prepare, and discuss. During the first step, “prioritize,” CMS and NQF prioritized programs for discussion. During the second step, “survey,” the MAP Workgroup and Advisory Group members nominated measures that they would like to discuss for potential removal via a survey process. Today marks the beginning of the third step, “prepare,” where NQF has prepared and posted the narrowed list of measures (XLSX) for public comment through May 25, 2022, at 6:00 PM ET.

This list outlines 32 measures for public comment that expand across six federal programs. These include 10 measures from the Home Health Quality Reporting Program (HH QRP), seven measures from the Merit-based Incentive Payment System (MIPS), seven measures from the Medicare Shared Savings Program (MSSP), five measures from the Hospital Outpatient Quality Reporting Program (Hospital OQR), two measures from the Ambulatory Surgical Center Quality Reporting (ASCQR) Program, and one measure from the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.

This public comment period provides an opportunity for stakeholders to weigh in on whether they think the measures that have been identified remain valuable to the programs they are in. While the focus of the effort is to facilitate measure removal, reduce burden, and improve focus on priority measures, it is also an opportunity for stakeholders to share their perspective on the importance of retaining measures in program(s). NQF encourages commenters to provide input based on the following questions:

• Does the measure contribute to the overall goals and objectives of the program?
• Does the measure result in better patient outcomes?
• Does the measure reflect the current evidence?
• Is there a high level of reporting burden for reporting entities?
• Does the measure have negative unintended consequences, including impacts to the rural population or contribution to health disparities?

During the final step of the MSR process, “discuss,” the MAP Advisory Groups, Workgroups, and Coordinating Committee will hold meetings open to the public to discuss measures and public comments and vote on decision categories. There are four 2022 MSR decision categories: support for retaining, conditional support for retaining, conditional support for removal, and support for removal.

The results of this effort will be published in a Draft Recommendations Report that will be available for public comment this summer. The Final Recommendations Report is expected to publish in the fall and will be one factor in CMS measure evaluations. Visit this page to learn more about MAP and upcoming activities. 

About National Quality Forum
The National Quality Forum (NQF) works with members of the healthcare community to drive measurable health improvements together. NQF is a not-for-profit, membership-based organization that gives all healthcare stakeholders a voice in advancing quality measures and improvement strategies that lead to better outcomes and greater value. Learn more at www.qualityforum.org.