- CMS carries over large amounts of funding available each year for programs measuring Medicare care quality and could devote more resources to tracking those programs because it "lacks complete information on its quality measurement funding and how it uses funding to achieve its strategic goals," according to a report from the U.S. Government Accountability Office.
- CMS spent an average of $43 million a year on quality measurement programs between fiscal year 2009 and 2018. Agency officials told GAO they used the funds conservatively to make sure there were no gaps in future years.
- The watchdog agency suggested CMS Administrator Seema Verma maintain more complete funding information, create a systematic assessment system for its quality measures, and develop and use a set of performance indicators to evaluate its progress.
As payers and providers embrace more value-based care and alternative payment models, how treatment quality is measured becomes a vital concern. CMS has only increased its reliance on payments that consider care quality metrics as it looks to push the industry out of a purely fee-for-service model.
But how care quality is measured has long been a contentious point. CMS is constantly refining its metrics and soliciting feedback. In 2017, the agency launched its Meaningful Measures initiative toward that end.
The metrics CMS uses are also picked up by private payers, so their selection and monitoring carries particular weight.
The Healthcare Integrated General Ledging Accounting System (HIGLAS) is CMS' method for accounting for the money the program is spending in all areas, including initiatives to measure the quality of care offered by providers for Medicare and Medicaid. In fiscal 2018, HIGLAS concluded that CMS spent $55.9 million on nine initiatives connected to quality reporting measures. However, the GAO concluded that the HIGLAS data "do not capture the total amount of funding CMS has obligated that pays for quality measurement activities."
Yet agency leadership bristled against not having a full accounting of how funds are being spent on quality measurement and how it drives the goals of the agency. CMS officials told the GAO "that they considered it unduly burdensome to attempt to use HIGLAS to track quality measurement funding according to their strategic objectives."
They added that such measures make up a tiny part of the spending being tracked by HIGLAS, and that CMS' objectives change over time anyway. Instead, CMS often relies on manual tabulation of how money is spent, including reviewing contracts.
As a result of its accounting gap, when CMS issued its first mandatory report on quality measurement funding last March, it was only able to break out funding into four broad categories with few specifics. "More detailed funding information could help the Congress to better understand how CMS is using appropriations for quality measurement, and could assist with effective oversight of these activities," the report noted, adding that "internal control standards call for agencies to consider the needs and expectations of external users, such as Congress, when collecting and communicating information."
And even if CMS' strategic objectives shift as the agency claims, there is often a gap in how the quality measurements are constructed in order to fulfill them.
The GAO has concluded that "CMS has not developed and implemented performance indicators that would be needed to determine if it is making progress in meeting its quality measurement strategic objectives." It noted, for example, that as of the 2018 fiscal year CMS was still not measuring whether its Medicare programs addressed issues such as community engagement and equity of care.
Moreover, the GAO concluded that "without more complete information on the total amount of funding obligated to quality measurement activities, CMS officials cannot accurately assess the magnitude of resources they have provided for quality measurement."