Multi-Stakeholder Group Input on Quality Measures

Pre-Rule Making

Statutory Requirement

Section 3014 of the Affordable Care Act of 2010 (ACA) (P.L. 111-148) created a new section 1890A  of the Social Security Act, which requires that Department of Health and Human Services (DHHS) establish a federal pre-rulemaking process for the selection of quality and efficiency measures for use by (DHHS).  The categories of measures are described in section 1890(b)(7)(B) of the Act.  The pre­ rulemaking process includes the following steps:

  1. Annually, not later than December 1st, DHHS makes publicly available, a List of quality and efficiency measures DHHS is considering adopting, through the federal rulemaking process, for use in Medicare program(s);
  2. Multi-stakeholder groups provide input not later than February 1st annually to DHHS on the selection of quality and efficiency measures;
  3. DHHS considers the multi-stakeholder groups’ input in selecting quality and efficiency measures;
  4. Program owners publish in the Federal Register the rationale for the use of any quality and efficiency measures that are not endorsed by the consensus based entity with a contract under Section 1890 of the Act, which is currently the National Quality Forum (NQF); and
  5. Assess the quality and efficiency impact of the use of endorsed measures and make that assessment available to the public at least every three years.


Fulfilling DHHS’s Requirement to Make Its Measures under Consideration Publically Available

Step one above under ‘Statutory Requirement’ explains the DHHS’ statutory requirement to annually issue a Measures under Consideration List to comply with the law.  Beginning with the first pre-rule making cycle in 2011, and each subsequent year after around second quarter through a call for quality and efficiency measures, CMS begins the annual pre-rule making cycle of collecting and compiling quality and efficiency measures for the Measures under Consideration List using an issue tracking system.  In addition, CMS may submit ad hoc Measures under Consideration Lists that would be in addition to the regular annual pre-rule making cycle.  CMS seeks to be inclusive with respect to new measures on this List.  For example, two meetings are convened to obtain input and consensus on this List from across DHHS.  Further, at the beginning of each pre-rule making cycle, non-Federal stakeholders are invited to submit proposed quality and efficiency measures. 

CMS will continue aligning measures across programs whenever possible, including establishing “core” measure sets, and, when choosing measures for new programs, it will look first to measures that are currently in existing programs.  CMS’ goal is to fill critical gaps in measurement that align with and support the CMS and the National Quality Strategy.  CMS programs must balance competing goals of establishing parsimonious sets of measures, while including sufficient measures to facilitate multi-specialty provider participation. 

Guidelines for Proposing Measures

The final annually published Measures under Consideration List identify quality and efficiency Measures under Consideration by the Secretary of DHHS for potential use in Medicare program(s).  These programs are defined in the statute.

Several important points to consider and highlight:

  • If CMS chooses not to adopt a measure under the Measures under Consideration List for the current rule-making cycle, the measure remains under consideration by the Secretary and may be proposed and adopted in subsequent rulemaking cycles; 
  • Existing measures that are proposed for expansion into different CMS programs should be submitted on subsequent Measures under Consideration Lists;
  • Some measures are part of a mandatory reporting program.  However, a number of measures, if adopted, would be part of an optional reporting program.  Under this type of program, providers or suppliers may choose whether to participate;
  • The annual Measures under Consideration List includes measures that CMS is currently considering for Medicare program(s).  Inclusion of a measure on the List does not require CMS to adopt the measure for the identified program.  All measures included on the annual pre-rule making List are subject to CMS’ rule-making process;
  • In an effort to provide a more meaningful List, CMS will only include measures that have reached a level of maturity, which allows for meaningful review and are beyond conceptual;  
  • Proposed measure submissions will be accepted if the measure was previously proposed to be on a prior year's published Measures under Consideration List, but was not accepted by any CMS program(s); and
  • Measure specifications may change over time, if a measure has significantly changed, the changed measure must be submitted for each applicable program on a subsequent Measures under Consideration List.


Fulfilling Multi-Stakeholder Group Input Requirements

Step two, three, and four above under ‘Statutory Requirement’ describe in brief DHHS’ requirement to convene multi-stakeholder groups to provide consensus based input for the annual Measures under Consideration List.  The multi-stakeholder groups are convened by the consensus-based entity, which is currently under contract with the National Quality Forum (NQF) to oversee this work.  The Measure Applications Partnership (MAP) was launched in the spring of 2011.  The MAP’s overriding goal intent and under statute is to maintain transparency for the public and encourage public engagement throughout the work.  All MAP meetings are open to the public and meeting summaries are posted on the NQF website.  MAP will continue to seek public comment on all input to DHHS. 

In order to provide input for the Measures under Consideration measures, the MAP developed Measure Selection Criteria to evaluate the proposed measures.  The workgroups will reach one of the three conclusions for each of the potential measures:  support the measure, do not support the measure, or conditionally support the measure.  DHHS is required to take MAP’s analysis and advice into account, but the final decisions about measure selection and implementation in public programs are solely in DHHS’ authority.  If DHHS decides to implement a proposed nonsupported measure for rule-making via the Federal Register process, a rationale for that decision will be provided by CMS. 

After receiving the annual Measures under Consideration List no later than December 1st, each winter (i.e., December and January) the MAP workgroups and Coordinating Committee convene to fulfill its statutory requirement of providing input to DHHS on Measures under Consideration for use in Medicare programs.  Beginning February 1, 2012, the MAP provided program-specific recommendations to DHHS and no later than February 1st through the present year.

As a resource, reference materials are located below to assist and support CMS’ annual pre-rule making processes.