Health care quality measurement serves an important role in ensuring that patients receive high quality care, identifying areas for improvement, and facilitating accountability.[i] The role of quality measures will continue to expand, in part with the shift towards alternative payment methods (APMs) through which payments to providers are tied to quality performance and cost efficiency.[ii],[iii],[iv] Through global budget-based risk contracts, a type of APM, providers assume a degree of financial risk for a population of attributed patients and may earn financial incentives for meeting agreed-upon quality performance targets.[v] While quality measurement continues to be valuable for patient care and payment, a lack of alignment in the specific measures used in global-budget-based risk contracts is a major source of administrative burden in the health care system, contributing to clinician burnout and diluting quality improvement efforts.[vi]
Recognizing these challenges, the Executive Office of Health and Human Services (EOHHS), in collaboration with the Massachusetts Health Policy Commission (HPC) and the Center for Health Information Analysis (CHIA), convened the Quality Measure Alignment Taskforce (“Taskforce”) in 2017. The primary goal of the Taskforce has been to propose an aligned set of quality measures for use in global budget-based risk contracts between payers and providers in the Commonwealth. Adoption of a single, expert-informed set of quality measures would simplify administration for both providers and payers, emphasize the state’s quality improvement priorities, and enable state agencies to better monitor health system performance overall.
Members of the Taskforce include individuals with quality measurement expertise from provider organizations, commercial and Medicaid managed care health plans, academic institutions, state agencies, and consumer advocacy organizations. Through a consensus process, the Taskforce developed and maintains the Massachusetts Aligned Measure Set, a standard set of quality measures and specifications that is reviewed and updated on an annual basis. The Commonwealth currently relies on voluntary adoption of the Massachusetts Aligned Measure Set by providers and commercial payers.
To track adoption of the Aligned Measure Set by Massachusetts payers, the Taskforce annually administers a voluntary survey, the Quality Measure Catalogue, to learn which quality measures payers have included in their global budget-based risk contracts for the upcoming year in order to measure adherence. This analysis focuses on survey responses from five commercial payers—Blue Cross Blue Shield of Massachusetts (BCBSMA), Boston Medical Center HealthNet Plan (BMCHP), Harvard Pilgrim Health Plan (HPHC), Health New England (HNE), and Tufts Health Plan (THPP)—and MassHealth, Massachusetts’ Medicaid agency, for contract years 2019 through 2021.1
In addition, Taskforce staff interviewed all payers that contributed to the Quality Measure Catalogue to gather qualitative insights into their adoption of the Massachusetts Aligned Measure Set.
This DataPoints issue was prepared in collaboration with the Center for Health Information and Analysis (CHIA). The purpose of this DataPoints issue is to promote transparency on current payer adherence to the Massachusetts Aligned Measure Set. The below interactive graphics display best in full-screen mode. To view them in full screen, scroll to the bottom of each graphic and click on the far-right icon. Use the same icon to return to the original view.
Overview of the Massachusetts Aligned Measure Set
The Taskforce has defined six categories of measures, five of which make up the Massachusetts Aligned Measure Set (“Aligned Measure Set”)—Core, Menu, Developmental, Innovation, and On Deck measures (hover over the pie slices for more information on the measure category definitions). Payers and providers are expected to adopt all Core measures, can choose measures from the Menu set, and/or can choose to pilot Developmental, Innovation, or On Deck measures. The Taskforce tracks Monitoring measures, but use of Monitoring measures in contracts is not considered to be in adherence with the Aligned Measure Set given that performance on those measures is already high and there is limited opportunity for improvement; should performance for those measures decline, the Taskforce may consider moving them into the Core or Menu sets.
Payer Use of 2021 Core and Menu Measures in Any Global Budget-Based Risk Contract
The Taskforce adjusts the composition of the Aligned Measure Set slightly from year to year as measures are added or retired. The 2021 Massachusetts Aligned Measure Set consists of four Core Set measures and 21 Menu Set measures. Overall, the payers of focus increased the use of four measures from the Aligned Measure Set in their contracts from 2020 to 2021, one of which is a Core measure and three of which are Menu measures. Payers decreased the use eight measures, one Core measure and seven Menu measures, in their contracts from 2020 to 2021.
Use of behavioral health measures has been low overall, with only two out of eight included in contracts by more than one payer.
Massachusetts Aligned Measure Set Adherence Rate
Adherence to the Aligned Measure Set has been calculated by taking the sum of instances endorsed measures were used by a given payer in their global budget-based risk contracts and dividing it by the sum of instances any measures (endorsed or non-endorsed) were used by a given payer in their global budget-based risk contracts.
The overall adherence rate to the Aligned Measure Set among respondents has increased from 65% in 2019 to 83% in 2021. However, there is wide variation in adherence among payers. Two of the commercial payers who responded to the Quality Measure Catalogue, BCBSMA and HPHC, had a meaningful increase in their adherence rate to the Aligned Measure Set between 2019 and 2021. On the other hand, BMCHP, THP, and HNE have not made meaningful improvements in their adoption of the Aligned Measure Set.
In follow-up interviews, payers cited some potential barriers to adoption of the Aligned Measure Set, including multi-year contracts which do not adjust to annual changes in the Aligned Measure Set during the contract period; provider requests to use non-endorsed measures; plan interest in use of non-aligned HEDIS measures NCQA considers for plan accreditation; insufficient denominators for certain measures; and the burden of collecting outcome measures which rely on clinical data from electronic health records (EHRs). It is worth noting that MassHealth does include some population-specific measures which are not part of the Aligned Measure Set, but have been endorsed by the Taskforce for use in MassHealth ACO contracts.
Overall adherence has increased, although there is wide variation in adherence among payers.
The goal of universal adoption of the Massachusetts Aligned Measure Set is to reduce the administrative burden for payers and provider organizations and focus the Commonwealth’s quality improvement efforts on high priority areas. The overall trend in adoption of the Massachusetts Aligned Measure Set from 2019 to 2021 is positive, but adherence is variable and there continue to be multiple measure sets used in global budget risk contracts. While voluntary payer commitments to alignment show promise, absent a legislative mandate, it is unlikely that full alignment will be achieved.
For more information on the EOHHS Quality Measure Alignment Taskforce, please visit their website.
1. United HealthCare was excluded from this analysis as they only submitted data for one year; Allways Health Partners and UniCare reported that they do not use quality measures in global-budget based risk contracts as the Taskforce has defined those contracts, and Aetna, Cigna, and Commonwealth Care Alliance did not respond to the request.
[i] Massachusetts Executive Office of Health and Human Services Quality Alignment Taskforce Report on Work through July 2018 (October 2018). Available at: https://www.mass.gov/doc/eohhs-quality-alignment-taskforce-report-on-work-through-july-2018-october-2018/download
[ii] Patient Protection and Affordable Care Act, Public law 111-148 (2010).
[iii] An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation, Chapter 224 (2012).
[iv] Medicare Access and CHIP Reauthorization Act of 2015, Public law 114-10 (2015)
[v] Health Policy Commission. Transforming Care: Risk Contracts and Performance Management Approaches of Massachusetts ACOs. (June 2019). Available at: https://www.mass.gov/doc/aco-brief-3-transforming-care-risk-contracts-and-performance-management-approaches-of/download
[vi] Health Policy Commission. Pre-filed Testimony Pursuant to the 2016 Annual Cost Trends Hearing. 2016 Oct. Available at: https://www.mass.gov/service-details/testimony-2016-cost-trends-hearing
Massachusetts Health Policy Commission. DataPoints Issue 21: The Quality Measure Alignment Taskforce’s Evaluation of Payer Adherence to the Massachusetts Aligned Measure Set. Feb. 9, 2022. Available at: https://mass.gov/info-details/hpc-datapoints-issue-21