The passage of the Tax Relief and Health Care Act of 2006 (TRHCA), which requires hospitals serving Medicare beneficiaries to report hospital outpatient quality data to secure their full Outpatient Prospective Payment System (OPPS) fee schedule update, has precipitated a need to identify performance measures applicable to the hospital outpatient setting. RAND’s environmental scan provides a preliminary assessment of the measures landscape in the context of care provided in the hospital outpatient setting, by determining the leading conditions treated and services/procedures provided in the hospital outpatient setting and by identifying existing and potentially relevant performance measures as well as gaps in measures. Below we highlight the key findings and describe next steps the Centers for Medicare and Medicaid Services (CMS) could consider as it works to develop its performance measurement agenda for this setting.
A small number (10) of hospital outpatient measures comprise the initial measure set to be used in the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), and CMS has another 30 candidate measures that it has put forth for public comment. Our review found that there are approximately 700 publicly available, existing inpatient and ambulatory care measures that may be potentially applicable to the types of conditions treated and services/procedures provided in the hospital outpatient setting. While the vast majority of existing measures assess clinical effectiveness, primarily underuse of services, there are a few measures that address other care domains identified in the 2001 Institute of Medicine (IOM) Crossing the Quality Chasm report as critical to enhancing system performance, such as patient experience with care and patient safety. Among the next steps that CMS could consider are to: (1) conduct a more detailed mapping of existing measures to specific areas of care provided in the hospital outpatient setting, and (2) for those measures that are directly relevant, adapt the technical specifications for this setting of care, which may provide a near-term source of additional candidate measures for the HOP QDRP. Broadening the use of existing measures also will help to align measurement and accountability across various Medicare settings.
Although the many existing measures that RAND identified hold the promise of applicability to the hospital outpatient setting, there are gaps. Some examples include measures of cancer care (e.g., lung cancer); specialty care; follow-up care; coordination-of-care/transitions-in-care; transmission of test results; outcomes; episodes of care; and measures of high-volume/high-cost drugs/biologicals (e.g., blood products; thrombolytic agents). In the use of various services/procedures, such as imaging, there is an absence of measures that address appropriate use — which is a critical issue given that services/procedures are a key driver of the cost growth within the hospital outpatient setting. To the extent that CMS also wishes to address the various domains highlighted in the 2001 IOM report, there are also gaps in available measures of efficiency, equity, and timeliness of care.