Fast Facts

How does Medicare ensure that hospitals, physicians, and others are providing high-quality health care?

Medicare can adjust payments based on performance, but it also keeps providers accountable by making health care quality information publicly available. Medicare has made it a priority to develop and use measures of health care quality that address key aspects of care while minimizing the data reporting burden on providers.

However, it isn’t always clear that Medicare’s measures address its priorities. We recommended ways to ensure Medicare’s priorities drive its quality measurement activities.

Stethoscope and a calculator on top of a medical bill

Stethoscope and a calculator on top of a medical bill

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Highlights

What GAO Found

The Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), maintains information on the amount of funding for activities to measure the quality of health care provided under Medicare. CMS's information shows it has carried over from each year to the next large amounts of available funding—known as unobligated balances—for quality measurement activities from fiscal years 2010 through 2018 (see figure). CMS officials said they maintained such available funding to ensure there were no gaps in funding for future years. However, CMS officials also told GAO that the information it maintains does not identify all of the funding the agency has obligated for quality measurement activities. Further, it does not identify the extent to which this funding has supported CMS's quality measurement strategic objectives, such as reducing the reporting burden placed on providers by CMS's quality measures. With more complete and detailed information, CMS could better assess how well its funding supports its quality measurement objectives.

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CMS takes different approaches for deciding which quality measures to develop and to use. However, CMS lacks assurance that the quality measures it chooses address its quality measurement strategic objectives. This is because CMS does not have procedures to ensure systematic assessments of quality measures under consideration against each of its quality measurement strategic objectives, which increases the risk that the quality measures it selects will not help the agency achieve those objectives as effectively as possible. These procedures, such as using a tool or standard methodology to systematically assess each measure under consideration, could help CMS better achieve its objectives. In addition, CMS has not developed or implemented performance indicators for each of its quality measurement strategic objectives. Establishing these indicators and using them to evaluate its progress towards achieving its objectives would enable CMS to determine whether its quality measurement efforts are sufficient or changes are warranted.

Why GAO Did This Study

To encourage greater value in health care, CMS adjusts its Medicare payments to many health care providers based on measures of the quality of care. Therefore, the decisions CMS makes to choose certain quality measures have significant consequences. These decisions may involve selecting specific existing measures for CMS to use, stopping the use of some measures, or identifying new measures to be developed.

The Bipartisan Budget Act of 2018 contains a provision for GAO to review CMS's quality measurement activities. For this report, GAO (1) assessed the information CMS maintains on funding of health care quality measurement activities, and (2) described and assessed how CMS makes decisions to develop and to use quality measures. GAO analyzed CMS funding data for 2009 through 2018 and data on CMS quality measurement selections for 2014 through 2018. GAO reviewed CMS documentation related to its decisions on quality measurement and interviewed program and contractor officials.

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Recommendations

GAO recommends that CMS (1) maintain more complete and detailed information on its funding for quality measurement activities, (2) establish procedures to systematically assess measures under consideration based on CMS's quality measurement strategic objectives, and (3) develop and use performance indicators to evaluate progress in achieving its objectives. HHS concurred with all three recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare and Medicaid Services The Administrator of CMS should, to the extent feasible, maintain more complete information on both the total amount of funding allocated for quality measurement activities and the extent to which this funding supports each of its quality measurement strategic objectives. (Recommendation 1)
Open
As of June 2021, HHS reported that it is in the process of implementing a new budget system that will improve its ability to track how its budgetary allocations align with its quality strategic plan. Once this system is operational, GAO will assess the extent to which it provides the capabilities called for in this recommendation.
Centers for Medicare and Medicaid Services The Administrator of CMS should develop and implement procedures to systematically assess the measures it is considering developing, using, or removing in terms of their impact on achieving CMS's strategic objectives and document its compliance with those procedures. (Recommendation 2)
Open
As of June 2021, HHS reported that it is in the process of revising its Meaningful Measures framework and completing its development of a Quality Measure Index. These are the mechanisms through which HHS expects to achieve a more systematic assessment of the quality measures that it considers, as GAO recommended. Once HHS issues its revised Meaningful Measures framework and begins to utilize its Quality Measure Index, GAO will assess the extent to which HHS's application of these tools address this recommendation.
Centers for Medicare and Medicaid Services The Administrator of CMS should develop and use a set of performance indicators to evaluate the agency's progress towards achieving its quality measurement strategic objectives. (Recommendation 3)
Open
As of June 2021, HHS reported that it is in the process of refining its Meaningful Measures framework. As part of that process, the department stated that it plans to obtain input, presumably from outside stakeholders, to help guide its development and implementation of performance indicators for its quality measurement strategic objectives. Once HHS completes development and begins to use performance indicators for its quality measurement strategic objectives, GAO will assess the extent to which these actions address this recommendation.

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