GAO: Misalignment of health care quality measures

By United States Government Accountability Office
Report to Congressional Committees, October 2016

Health Care Quality

HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures

What GAO Found

While the full extent of misalignment among health care quality measures is unknown, it can have adverse effects on providers and efforts to improve quality of care. Misalignment occurs when health care payers require providers to report on measures that focus on different quality issues or define the measures using different specifications. GAO identified three studies that provided some information on the extent of misalignment. For the most part, these studies examined the number of measures that were used in common, among a narrow selection of public and private payers, and found that with few exceptions, only a small proportion of measures were commonly used by these payers. The Department of Health and Human Services’ (HHS) Centers for Medicare & Medicaid Services (CMS) agrees that misalignment exists, and some experts note that it adds to providers’ administrative burden and often results in quality information that is not comparable.

Factors Driving Misalignment of Health Care Quality Measures

*  Dispersed decision-making:  Among public and private payers and other stakeholders, each entity independently decides which quality measures it will use and which specifications should apply to those measures.

*  Variation in data collection and reporting systems:  Payers may choose different measures, or leave details about measure specifications up to providers in order to accommodate differences in data that providers collect and the systems they use to collect these data.

*  Few meaningful measures:  Although hundreds of quality measures have been developed, relatively few are measures that payers, providers, and other stakeholders agree to adopt, because few are viewed as leading to meaningful improvements in quality.


The use of health care quality measures is central to HHS’s and other payers’ efforts to improve health care quality. While quality measures can encourage improvements in care, they can also be burdensome to providers when the measures are misaligned and providers have to report different quality measures to different health care payers. Such misalignment has the potential to affect the success of HHS’s efforts to pay providers based on the quality of care they provide. HHS has acknowledged the need to substantially improve quality measurement for physicians and other providers, and has a stated goal of improving alignment between federal and private payers.

Although HHS has initiated a range of different efforts to reduce misalignment, we identified two deficiencies in these efforts. First, HHS has not prioritized the development of electronic quality measures with standardized data elements for the core sets of aligned measures. CMS and private payers have prioritized certain quality measures to be used in common so alignment is improved, but HHS has not focused resources on developing electronic quality measures for these quality measures. As providers increasingly use EHRs, HHS has the opportunity to pursue its stated objective to develop electronic quality measures that would allow physicians to collect automatically much of the clinical information needed for these measures as part of their normal clinical workflow, with a consequent decrease in the administrative burden faced by physicians.

Second, CMS has not comprehensively planned its measure development efforts to ensure the development of new, more meaningful quality measures targeted to reduce misalignment, which could jeopardize CMS’s efforts to achieve that goal. Some experts we interviewed told us that the paucity of meaningful measures makes it difficult for payers and providers to agree on aligned measures. In contrast, developing new, more meaningful measures to replace older, less meaningful ones could help to promote further agreement on aligned measures and gain broader support from physicians. However, CMS’s plans do not indicate how its efforts will target new measures that will lead to greater alignment, rather than simply adding to the array of available quality measures that has led to misalignment in the past.



By Don McCanne, M.D.

The mantra today is to pay for quality instead of quantity, and the government and private sector are rapidly moving ahead with administratively burdensome programs to implement this vision. But they left out a step. As this GAO report reveals, they have not developed a program that can adequately measure quality.

Measuring minutia that does not represent even one percent of health care - measures that also are misaligned between the various stakeholders - can hardly give a fair assessment of the quality of health care services delivered. Plans to add more measurements of minutia certainly will not help much.

Yet these almost worthless measurements are adding to the administrative burdens and costs of our health care system while intensifying physician burnout. Further, they are being used to assess financial penalties against the providers, and to shame providers through public reporting of quality ratings. Talk about depressing.

If we want real quality in health care, we need to do it through structural reform. We need to quit listening to Orszag, Emanuel, McClellan, and the others who support simple sound bites rather than effective policy on improving quality. Instead we should move forward with the model presented in a JAMA article over two decades ago: “A Better-Quality Alternative: Single-Payer National Health System Reform” by Gordon Schiff and his working group colleagues. The link: