Quality Measures

What are quality measures?

Quality measures are validated metrics used by various organizations to assess specific process or health outcomes in the real world. They can be used in order to assess how well an entity is doing in caring for specific populations and some payers, namely the Centers for Medicare and Medicaid (CMS) services, use them to influence reimbursement. The ultimate goal of quality measures is often to improve clinical outcomes as well as give consumers information on how certain plans or providers might compare.

Development of quality measures can be complicated as a number of issues including data availability, potential for confounding, validity of measures, and selection bias in comparing different populations have to be considered. This is especially true when these measures are tied to reimbursements as certain populations may do worse due to things outside of a plan or provider’s control (eg populations of lower socioeconomic status may have worse outcomes due to social determinants of health not tied to the provision of healthcare).

CMS uses the Stars program to rate Part C and D plans on a number of measures including use of statin therapy in patients with cardiovascular disease, percentage of population getting the annual flu vaccine, blood sugar control amongst diabetics, and patient complaints about the plan.