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Working for Quality > About the NQS > 2012 Annual Progress Report to Congress National Strategy for Quality Improvement in Health Care

2012 Annual Progress Report to Congress National Strategy for Quality Improvement in Health Care (continued)

A National Approach to Measuring Quality

One of the primary purposes of the National Quality Strategy is to build a national consensus on how to measure quality. As we undertake the challenge of improving health care quality, our efforts must be driven by reliable data that the stakeholder community agrees encompasses the best and most relevant measures, without creating an undue burden of collection. Currently, health care quality is measured in many different ways, by many different entities and the results are often not comparable. The National Quality Strategy prompted a review of existing programmatic measures, and identification of an approach to discontinue use of measures that may be duplicative or outdated.

Further, HHS will display the population-based quality outcomes data it collects in reports that are aligned with the National Quality Strategy priority areas. The National Health Quality and Disparities Reports (NHQR-DR), existing annual reports since 2003, will now be organized according to the 6 priority areas of the National Quality Strategy, making clear how the national measures reported in the NHQR-DR relate to our shared national priorities.

Focusing on Clinical and Patient-Reported Outcomes

Historically, quality measurement has relied primarily on clinical process measures. Under the guidance of the National Quality Strategy, measures increasingly focus on clinical outcomes and patient-reported outcomes and experience. These patient-reported measures include care transition experiences and changes in patient functional status. Measures should be defined as close to the patient-centered outcome of interest as possible.

Over the past year, numerous programs have adopted patient-reported clinical outcomes and patient-reported experience measures. For example, the Hospital Value-Based Purchasing Program has incorporated 30-day condition-specific mortality measures as well as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) into its measure set, linking clinical outcomes and patient-reported experience of care to provider payment. The End-Stage Renal Disease Quality Incentive Program for dialysis facilities also directs providers to administer an in-center dialysis patient experience survey, ensuring that Medicare beneficiaries with end-stage renal disease receive high quality, patient-centered care.

HHS is also continuing to identify and facilitate the development of new patient-centered outcome measures. For example, the 3-item care transition measure (CTM-3)3 is under consideration by the Centers for Medicare & Medicaid Services for rulemaking in 2012. This patient-reported measure captures elements of the care transition process (e.g., medication management and patient self-care following discharge) that patients deem critically important to their experience during discharge from the hospital. Additional work is underway to expand the Department's portfolio of outcome measures across care settings and types of measurement.

New Transparency in HHS Selection of Quality Measures

The Affordable Care Act also calls for additional transparency in the selection of measures used in HHS programs. Specifically, Section 3014 of the Affordable Care Act requires the establishment of a Federal “pre-rulemaking process” for the selection of quality and efficiency measures for qualifying programs within HHS. This new process has been established and includes the following steps:

  • Each year, by December 1, HHS will make publicly available a list of measures under consideration for qualifying programs within the Department.
  • Multi-stakeholder groups will be provided the opportunity to review and make comments by February 1 of each year.
  • HHS will publish the rationale for the selection of any non-NQF endorsed quality and efficiency measures to be used in a qualifying program.
  • HHS will assess the impact of endorsed quality and efficiency measures at least every 3 years (the first report was published in March 2012).4

This process is already in use via the convening of the Measures Application Partnership and posting of their draft deliberations for public comment. On December 2, 2011, CMS published a list of 368 measures under consideration for the 2012 rulemaking process.5 On February 1, the Measures Application Partnership submitted its first annual pre-Federal rule making report.6 CMS is currently reviewing the recommendations for its annual rulemaking regarding quality measures used in Medicare. More information about this process, the measures, and multi-stakeholder group review is available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/MultiStakeholderGroupInput.html.

Alignment with the National Quality Strategy: Selection and Removal of Measures

The proliferation and use of quality measures across settings and by numerous programs has created an increasingly complex environment for healthcare providers with an often burdensome volume of measurement. Efforts are underway within and across HHS agencies to minimize that burden and assure focus on National Quality Strategy priorities.

For example, upon the launch of the Million Hearts campaign, an HHS taskforce identified that different agencies and programs were using several different measures for blood pressure control, each measure with its own slightly different specifications. This required providers to collect the same information in multiple ways and the resulting statistics were not comparable. This taskforce forged consensus on a common set of specifications which will soon be used across all HHS programs.

Further, immediately upon the March 2011 release of the National Quality Strategy, the HIT Policy Committee (a federal advisory committee that provides health IT policy recommendations to HHS) established the six National Quality Strategy priorities as the lens through which all Stage 2 Meaningful Use recommendations would be viewed. A focus on reducing quality-reporting burden on providers led to efforts to align quality measurement and reporting, as indicated in the proposed rule for Stage 2 Meaningful Use requirements. Specifically, an example from the proposed rule is that eligible professionals (e.g. physicians) could report measures once and receive credit for the Meaningful Use quality reporting requirements and the Physician Quality Reporting System (PQRS) requirements. CMS has stated its intent to continue to align measures across programs whenever possible to minimize burden on providers.

Through an internal Quality Measures Task Force, CMS is continuing this work to align the measures of its various programs. The Quality Measures Task Force conducts in-depth reviews of measures under consideration for selection or removal to achieve the following goals:

  1. Align measures across programs and HHS initiatives (e.g. measures for the Physician Quality Reporting System with the EHR Incentive Program and the HHS Million Hearts campaign).
  2. Align measures with the goals and priorities of the National Quality Strategy.
  3. Select as few measures as necessary to achieve National Quality Strategy goals
  4. Focus on measures of patient outcomes and patient experience of care.
  5. Remove measures that are no longer appropriate for reporting.

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Aligning Federal & State Efforts to the National Quality Strategy

Quality-improvement efforts are underway throughout the Federal government and in each of the States. One of the primary activities of the National Quality Strategy is to ensure that these efforts all support the same set of aims and that expertise and best practices are shared to accelerate success. For example, activities are well underway to assure that the National Quality Strategy supports and reinforces improvements in population health consistent with the strategic directions, priorities and recommendations of the National Prevention Strategy: America's Plan for Better Health and Wellness, and other national strategies to improve population health. In addition, the newly-established Interagency Working Group on Healthcare Quality will identify opportunities for streamlining or collaborating on similar efforts across the Federal government. HHS is also undertaking specific new activities, discussed below, to make sure that the Department is aligning its work directly to the National Quality Strategy aims and priorities.

Similarly, there are many opportunities to align Federal approaches to quality measurement and improvement with work happening at the State level. States are key engines of public health improvement and health care delivery for millions of Americans, and health care providers often face with different State and Federal measures or quality improvement priorities. The National Quality Strategy provides an opportunity for Federal government stakeholders to learn from State successes and shape national priorities accordingly, and an opportunity for States to evaluate their current efforts in light of the National Quality Strategy.

Agency-Specific Quality Strategic Plans

HHS is working with each of its component agencies to develop agency-specific plans to align their work with National Quality Strategy priorities and goals. HHS created a template to guide them in the development of these plans, with broad, recommended categories to create consistency across the plans and ensure alignment with the National Quality Strategy. In their plans, agencies explain how their own principles, priorities, and aims correspond with those of the National Quality Strategy; elaborate on their existing and future efforts to implement the National Quality Strategy; and discuss the methodology for evaluating these efforts.

All HHS agencies (AHRQ, CDC, CMS, HRSA, IHS, FDA, NIH, and SAMHSA) have completed their initial quality strategic plans. These completed Agency-Specific Strategic Plans can be found at www.ahrq.gov/workingforquality/. Future National Quality Strategy progress reports will highlight updates of these plans.

One example of this effort is the Substance Abuse and Mental Health Services Administration (SAMHSA), development of the National Behavioral Health Quality Framework to reflect a SAMHSA-specific approach to implementing the National Quality Strategy. The framework tailors each of the National Quality Strategy aims and priorities by narrowing the focus of each priority to behavioral health and providing goals and objectives to meet these priorities.

Aligning New Initiatives to the National Quality Strategy

HHS is working to ensure that every new initiative from the Department, as well as every new funding request, aligns to the National Quality Strategy. HHS developed an Agency-Alignment Checklist for agencies to report how newly proposed programs align with the National Quality Strategy aims and priorities. Agencies must complete this checklist when requesting approval of new programs or program funds. This new process will require decision-makers in the component agencies and the Department to proactively consider the National Quality Strategy when developing new programs and funding requests.

Alignment with States

States, local communities, and the private sector are essential partners in implementing the National Quality Strategy. In consultation with States, HHS has identified a core set of children's health measures for use in Medicaid and the Children's Health Insurance Program (CHIP).7 Using clear consistent measures will not only speed quality improvement for Medicaid and CHIP beneficiaries but also reduce administrative burdens for States. In January 2012, AHRQ and CMS released the initial core set of health care quality measures for adults eligible for benefits under Medicaid8 (the Annual report is available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2011_StateReporttoCongress.pdf). Leading States have also undertaken efforts to align their quality measurement and improvement efforts with the National Quality Strategy. HHS continues to work with States in this alignment process. Among those efforts, Colorado and Ohio stand out as leaders in State and Federal measure alignment. The sections below describe efforts currently underway by Colorado and Ohio to align quality initiatives with the National Quality Strategy.

Colorado: State Measurement Collaborative

The Colorado Department of Public Health and Environment (CDPHE), the Colorado Department of Health Care Policy and Financing (HCPF), and the Colorado Department of Human Services Division of Behavioral Health (DBH) began meeting in the Spring of 2011 to take steps toward aligning quality measures across the health care system in Colorado. Together, these three agencies provide a broad spectrum of physical and behavioral health care and public health services. These services involve prevention, early identification, treatment of disease and chronic conditions to Coloradans at all stages of life, from birth to old age. Over the past few months, a group from these three agencies has focused on quality improvements, by examining areas for collaboration and opportunities for improved measurement alignment.

Similar to the efforts of the National Quality Strategy, the goals of this group are to—

  • Develop more efficient systems to measure the effectiveness of the work of HCPF, DBH, and CDPHE in prevention of costly and preventable illness, access to the system and services once illness exists, satisfaction with the services, outcomes related to services, and coordination of services within the system.
  • Use these shared data to better understand both how Coloradans access the publicly funded health care system in Colorado, and the outcomes of their interactions with this system.
  • Provide an opportunity for a greater sense of shared vision on how to use data to enhance decision-making and support the creation of a shared vision and shared goals across agencies.

To achieve this, a group representing the three agencies has developed a core set of measures that are aligned with federal measurement initiatives and across programs. They organized these core measures into areas of priority for CDPHE, HCPF, and DBH including (1) Mental Health and Substance Abuse, (2) Obesity Nutrition and Fitness, (3) Oral Health, (4) Tobacco, (5) Unintended Pregnancy, (6) Emergency Room Visits, and (7) Hospital Readmissions.

To align measures and work across the State, Colorado used the National Quality Strategy and related Federal agency initiatives including the child and adult Medicaid and CHIP measures, SAMHSA's National Framework for Quality Improvement in Behavioral Health Care, and the Center for Disease Control and Prevention's “Winnable Battles.”9

In the upcoming months, these three State agencies will collaborate to share data. Sharing data will increase its utility to improve systems, care, and outcomes. By working together, these three State agencies can advance the three goals of the National Quality Strategy by efficiently using scarce resources to improve the health of all Coloradans.

Ohio Medicaid Quality Strategy

In 2011, Ohio revised its Medicaid Quality Strategy10 to align with the aims and priorities of the National Quality Strategy. Ohio's Medicaid Quality Strategy serves as the State's mechanism to monitor health plans and improve the delivery of health care services for Medicaid beneficiaries. The three aims of Ohio's Strategy are:

  1. Better Care: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe.
  2. Healthy People/Healthy Communities: Improve the health of the Ohio Medicaid population by supporting proven interventions to address behavioral, social, and environmental determinants of health.
  3. Practice Best Evidence Medicine: Facilitate the implementation of best clinical practices to Medicaid providers through collaboration and improvement science approaches.

Based on these aims, Ohio's Medicaid Quality Strategy has identified six initial clinical focus areas: high-risk pregnancy/premature births, behavioral health, cardiovascular disease, diabetes, asthma, and upper respiratory infections.

Ohio Medicaid identified quality performance measures for the six clinical focus areas to hold health plans accountable for improving performance. In addition, Ohio will provide performance incentives to health plans that in these areas and will penalize plans that fail to meet standards.

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Focus on Priorities: Key Measures and Long Term Goals

At the heart of the National Quality Strategy are six priorities, which will focus national quality improvement efforts. Since establishing these priorities, the National Quality Strategy has added more detail on how it will pursue — and measure — improvement in these areas. The additional details below – key measures, aspirational targets, and long-term goals – are the result of stakeholder engagement, measure review, and governmental harmonization efforts described earlier in this report.

The key measures proposed in this year's National Quality Strategy were chosen based on the National Priorities Partnership's list of 59 measure concepts,11 as well as current capabilities to obtain reliable, nationally-representative data. In some priority areas, the aspirational targets reflect specific goals of new public-private partnerships established during 2011 (e.g., the Partnership for Patients and the Million Hearts campaign). For all priorities, future updates to the National Quality Strategy will use the measures below – as well as other consensus measures where appropriate – to set aspirational targets and track the progress of improvement efforts in each priority area.

In addition, the National Quality Strategy sets goals for long-term improvement in each priority area, which were largely adopted from National Priorities Partnership recommendations and will be assessed through key measures identified in this update or in future reports. These long-term goals are system wide objectives that can only be achieved through broad engagement of stakeholders.

Priority 1. Making Care Safer by Reducing the Harm Caused in the Delivery of Care

Health care-related errors continue to account for a significant amount of harm and death in the American health care system each year. The CDC estimates that healthcare-associated infections affect approximately 5% of hospitalized patients. Health care-related errors also impose a financial burden on the system; patients that do not die from a medical error often have longer and more expensive hospital stays. Eliminating health care associated infections and reducing the number of serious adverse medication events are important opportunities for success in making care safer.

In 2009, HHS released the National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination, and since then we have seen significant improvements in reducing the targeted infections. In 2010, there were 33 percent fewer central line associated blood stream infections (CLABSIs) and an 18 percent reduction in MRSA infections when compared to the baseline period.12 To build on these achievements, and to expand our focus to include other types of harm, HHS launched the Partnership for Patients, described below.

Nationwide Initiative—The Partnership for Patients is a national patient safety and quality improvement initiative that has two goals: reducing preventable hospital-acquired conditions by 40 percent, and reducing 30-day hospital readmissions by 20 percent by the end of 2013. Through the Partnership, the CMS Center for Medicare and Medicaid Innovation (CMMI or Innovation Center) is investing up to $500 million in public-private hospital engagement networks that will help hospitals adopt proven strategies to reduce hospital-acquired conditions in their own facilities. So far, these hospital engagement networks include more than 3,900 hospitals nationwide, and quality improvement work is well underway.

As part of the Partnership, CMS is also investing $500 million in the Community-based Care Transitions Program to reward hospitals, physicians, and those who partner with them to keep high-risk Medicare beneficiaries out of the hospital after discharge. (http://www.healthcare.gov/center/programs/partnership)

Long-Term Goals for Making Care Safer:

  1. Reduce preventable hospital admissions and readmissions.
  2. Reduce the incidence of adverse health care-associated conditions.
  3. Reduce harm from inappropriate or unnecessary care.

Exhibit 2. Key Measures for National Quality Strategy Priority 1—Making Care Safer by Reducing the Harm Caused in the Delivery of Care

Measure Focus Key Measure Name/Description Current Rate Aspirational Target
Hospital-acquired Conditions Incidence of measurable hospital-acquired conditions 145 HACs per 1,000 admissions* Reduce preventable HACs by 40% by the end of 2013
Hospital Readmissions All-payer 30-day readmission rate 14.4%, based on 32.9 million admissions* Reduce all readmissions by 20% by the end of 2013

*Source: Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, and Centers for Medicare and Medicaid Services, March 2012.

Priority 2. Ensuring That Each Person and Family Is Engaged in Their Care

The National Quality Strategy highlights the need to give individual patients and families an active role in the patient's care. Health care should adapt to individual and family situations (e.g., varying cultures, languages, disabilities, health literacy levels, and social backgrounds). Creating care practices that support patient and family engagement in understanding their treatment options helps them make decisions that align with their values and preferences. Opportunities to implement practices that promote person- and family-centered care include integrating patient feedback on preferences, functional outcomes, and experiences of care into all care settings and care delivery. Additional opportunities include increasing use of electronic health records (EHRs) that include patient-generated data in EHRs; and regularly measuring patient engagement and self-management, shared decision-making, and patient-reported outcomes.

Nationwide Initiative—Linking Patient Experiences to Provider Payment is now part of how Medicare pays for health care services. Through rigorous surveys measuring patient-provider communications and patient satisfaction known as Consumer Assessment of Health Care Providers and Systems surveys, Medicare learns which doctors and hospitals are successfully engaging patients in their care. Tying provider payments directly to patients' descriptions of their care experiences focuses the health care system on making sure that patients and their families are true partners in the prevention, diagnosis, treatment, and management of illness.

Providers participating in the Medicare Shared Savings Program will be measured by the surveys, and their scores will be a key determinant in how much they are eligible to earn through the program. (http://www.cms.gov/aco) In the fall of 2012, patient experience performance will be used to calculate value-based incentive payments to hospitals, meaning that hospitals that clearly communicate with patients and make the health care system easier to navigate will be paid more than those that do not. (http://www.cms.gov/Hospital-Value-Based-Purchasing)

Long-Term Goals for Engaging Patients and Families:

  • Improve patient, family, and caregiver experience of care related to quality, safety, and access across settings.
  • In partnership with patients, families, and caregivers—and using a shared decision making process—develop culturally sensitive and understandable care plans.
  • Enable patients and their families and caregivers to navigate, coordinate, and manage their care appropriately and effectively.

Exhibit 3. Key Measures for National Quality Strategy Priority 2—Ensuring That Each Person and Family Is Engaged in Their Care

Measure Focus Key Measure Name/Description Current Rate*
Timely Care Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted 14.4%**
Decision-making People with a usual source of care whose health care providers sometimes or never discuss decisions with them 13.2%**

* Source: Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey, 2010.
** Corrected May 2014.

Priority 3. Promoting Effective Communication and Coordination of Care

Care coordination is a conscious effort to ensure that all key information needed to make clinical decisions is available to patients and their providers. Patients commonly receive medical services, treatments, and advice from multiple providers in many different care settings, each focusing on a particular specialty. Less than sufficient provider-to-provider and provider-to-patient communication may lead to delays in treatment and dangerous errors in medical information. Enhancing teamwork and increasing use of health information technologies to facilitate communication among providers and patients can improve care coordination. Through the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, established by the Health Information Technology for Economic And Clinical Health (HITECH) Act, HHS has distributed more than $4.5 billion in incentive payments to nearly 1,700 hospitals and approximately 74,000 physicians and other health professionals who are using certified EHR systems that improve patient safety and coordination of care.

Multi-State Initiative—The Multi-payer Advanced Primary Care Practice Demonstration Revitalizing the Nation's primary care system is foundational to achieving high quality, accessible, efficient health care for all Americans. To that end, CMS is currently partnering with State Medicaid programs, private insurers, and employers to support primary care practices that emphasize prevention, health information technology, care coordination, and shared decision making between patients and their providers. In this demonstration Medicare participates in State-run, multi-payer collaboratives to support enhanced primary care services. Medicare pays monthly care-management fees for Medicare beneficiaries in those practices, and the other payers, including Medicaid, contribute for their patients. Taken together, these new resources allow practices to invest in nurse care managers, nutrition counseling, electronic medical records, and to spend more time with each patient. Eight states are currently participating: Maine, Michigan, Minnesota, New York, North Carolina, Pennsylvania, Rhode Island, and Vermont. Approximately 332,000 Medicare beneficiaries are receiving care from the participating practices.

Long-Term Goals for Promoting Effective Communication and Coordination of Care:

  1. Improve the quality of care transitions and communications across care settings.
  2. Improve the quality of life for patients with chronic illness and disability by following a current care plan that anticipates and addresses pain and symptom management, psychosocial needs, and functional status.
  3. Establish shared accountability and integration of communities and health care systems to improve quality of care and reduce health disparities.

Exhibit 4. Key Measures for National Quality Strategy Priority 3—Promoting Effective Communication and Coordination of Care

Measure Focus Key Measure Name/Description Current Rate
Patient-Centered Medical Home Percentage of children needing care coordination who receive effective care coordination 69%*
3-item Care Transition Measure* During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health
When I left the hospital, I clearly understood the purpose for taking each of my medications
Data available October 2012*

* Source: Health Resources and Services Administration, Maternal and Child Health Bureau; Centers for Disease Control and Prevention, National Center for Health Statistics, National Survey of Children's Health, 2007.
**This report will be updated online to reflect baseline performance data from the Centers for Medicare and Medicaid Services in October 2012.

Priority 4. Promoting the Most Effective Prevention and Treatment Practices for the Leading Causes of Mortality, Starting with Cardiovascular Disease

Providing high-value care to patients that improves the length and quality of their lives is the goal of health care. Focusing national quality improvement efforts on diseases that kill the most Americans places cardiovascular disease at the top of the list. Moreover, effective strategies for preventing and treating heart disease and strokes are well documented. The National Quality Strategy identifies increasing blood pressure control in adults, reducing high cholesterol levels in adults, increasing the use of aspirin to prevent cardiovascular disease for appropriate populations, and decreasing smoking among adults as important opportunities to prevent and treat cardiovascular disease.

Nationwide Initiative—The Million Hearts Campaign is a public-private sector initiative led by HHS to prevent 1 million heart attacks and strokes over the next 5 years. Cardiovascular disease is the leading cause of morbidity and mortality in the United States. Several preventive strategies can reduce the risk of developing cardiovascular disease: appropriate aspirin therapy for those who need it, blood pressure control, cholesterol management, and smoking cessation (the ABCS of cardiovascular disease). Among the many Millions Hearts activities are:
  • Educational efforts to increase awareness about heart disease and prevention and to demonstrate how individuals can take control of their heart health;
  • Discovery and dissemination of care practices that use interdisciplinary teams, health information technology, and incentives to optimize outcomes;
  • Improving adherence to appropriate medications for the ABCS.

Already, Million Hearts is partnering with many organizations around the country, including professional societies, consumer groups, employers and insurers. The Georgetown University School of Medicine, for example, has intensified its emphasis on the powerful preventive benefits of the ABCS and on the role of teams in effective care delivery. (millionhearts.hhs.gov)

Long-Term Goals for Promoting the Best Prevention and Treatment Practices for the Leading Causes of Mortality:

  1. Promote cardiovascular health through community interventions that result in improvement of social, economic, and environmental factors.
  2. Promote cardiovascular health through interventions that result in adoption of the most important healthy lifestyle behaviors across the lifespan.
  3. Promote cardiovascular health through receipt of effective clinical preventive services across the lifespan in clinical and community settings.

Exhibit 5. Key Measures for National Quality Strategy Priority 4—Promoting the Most Effective Prevention and Treatment Practices for the Leading Causes of Mortality, Starting with Cardiovascular Disease

Measure Focus Key Measure Name/Description Current Rate Aspirational Target
Aspirin Use People at increased risk of cardiovascular disease who are taking aspirin 47%* 65% by 2017
Blood Pressure Control People with hypertension who have adequately controlled blood pressure 46%** 65% by 2017
Cholesterol Management People with high cholesterol who have adequately managed hyperlipidemia 33%** 65% by 2017
Smoking Cessation People trying to quit smoking who get help 23%*** 65% by 2017

* Source: Centers for Disease Control and Prevention, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 2007-2008
** Source: Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey (NHANES), 2005-2008
*** Source: NAMCS, 2005-2008

Priority 5. Working with Communities to Promote Best Practices for Healthy Living

Population health is influenced by many factors, including genetics, lifestyle, health care, and the physical and social environment. It is important to acknowledge that a fundamental purpose of health care is to improve the health of populations. Acute care is needed to treat injuries and illnesses of short duration, and chronic disease management is needed to minimize the effects of persistent health conditions. However, preventive services that prevent the onset of disease encourage the adoption of healthy lifestyles, and help patients to avoid environmental health risks hold the greatest potential for maximizing population health. The National Quality Strategy identifies increasing the provision of clinical preventive services for children and adults, and increasing the adoption of evidence-based interventions to improve health, as important opportunities for success in promoting healthy living.

The Affordable Care Act requires many private insurance plans to provide coverage for and eliminate cost-sharing on certain recommended preventive health services, including colonoscopy screening for colon cancer, Pap smears and mammograms for women, well-child visits, flu shots for all children and adults, and many more. In addition, Medicare now covers recommended preventive services without coinsurance or deductibles. To date, more than 54 million Americans with private health insurance and 32.5 million Americans on Medicare have received at least one new preventive service without cost-sharing because of this provision. These changes in insurance coverage will be a significant driver, along with community-based initiatives, in achieving progress in this priority area.

HHS Initiative—The Community Transformation Grants program supports community-level efforts to reduce chronic diseases such as heart disease, cancer, stroke, and diabetes. By promoting healthy lifestyles, especially among population groups experiencing the greatest burden of chronic disease, this investment is intended help improve health, reduce health disparities, and control health care spending.

For example, Louisville, Kentucky is making healthy meals possible in school vending machines and through community gardens. This program builds on the lessons learned from its Healthy in a Hurry Program which featured healthy corner stores, fresh produce, and a produce manager hired from the neighborhood, and provided healthier options for 80,000 people.

In September 2011, the CDC awarded approximately $107 million in prevention funding to 61 states and communities and 7 national networks of community-based organizations serving approximately 120 million Americans. The CDC distributes these awards among State and local government agencies, tribes and territories, and State and local non-profit organizations. (http://www.cdc.gov/communitytransformation/)

Long-Term Goals for Working with Communities:

  1. Promote healthy living and well-being through community interventions that result in improvement of social, economic, and environmental factors.
  2. Promote healthy living and well-being through interventions that result in adoption of the most important healthy lifestyle behaviors across the lifespan.
  3. Promote healthy living and well-being through receipt of effective clinical preventive services across the lifespan in clinical and community settings.

Exhibit 6. Key Measures for National Quality Strategy Priority 5—Working with Communities to Promote Best Practices for Healthy Living

Measure Focus Key Measure Name/Description Current Rate
Depression Percentage of adults reported symptoms of a major depressive episode (MDE) in the last 12 months who received treatment for depression in the last 12 months 68.3%*
Obesity Proportion of adults who are obese 35.7%**

* Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies, National Survey on Drug Use and Health, 2010.
** Source: Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey (NHANES), 2010.

Priority 6. Making Quality Care More Affordable by Developing and Spreading New Health Care Delivery Models

For much of the past 30 years, health care costs have grown more quickly than income – burdening families, businesses, and government budgets alike. The National Quality Strategy identifies several important opportunities for success in making quality health care more affordable: building cost and resource use measurement into payment reforms, establishing common measures to assess the cost impacts of new programs and payment systems, reducing administrative burden, and making costs and quality more transparent to consumers. Many health care systems throughout the country are succeeding in taking advantage of these opportunities across their communities, and thereby delivering exceptional results for patients at lower than expected costs. Broad progress, however, has occurred unevenly. To accelerate the spread of effective delivery models that can improve health care quality and constrain cost growth, HHS is engaging with private and other public sector partners to provide payment and infrastructure support (e.g. health information technology) to health care providers committed to delivering three-part aim outcomes to their patients and communities.

Nationwide Initiative—The CMS Innovation Center was established by the Affordable Care Act as a new engine for testing innovative care delivery and payment models that have the potential to deliver better health care at lower cost for Medicare, Medicaid and CHIP beneficiaries. By supporting the efforts of doctors, hospitals, and other health care providers to improve the delivery of care in their local communities, the Innovation Center is helping to create a transformed health care system where providers work with engaged patients and are rewarded for keeping people well, not simply for delivering more services. The Innovation Center has launched initiatives involving thousands of providers that will touch the lives of Medicare and Medicaid beneficiaries in all 50 states. The results of these and other Innovation Center initiatives will be not only more sustainable public programs (Medicare, Medicaid, and CHIP) but ultimately a higher performing and more affordable health care system for all Americans. (www.innovations.cms.gov)

Long-Term Goals for Making Quality Care More Affordable:

  1. Ensure affordable and accessible high quality health care for people, families, employers, and governments.
  2. Support and enable communities to ensure accessible, high quality care while reducing waste and fraud.

Exhibit 7. Key Measures for National Quality Strategy Priority 6—Making Quality Care More Affordable by Developing and Spreading New Health Care Delivery Models

Measure Focus Key Measure Name/Description Current Rate
Out of Pocket Expenses Percentage of people under 65 with out-of-pocket medical and premium expenses greater than 10 percent of income 17.6%*
Health spending per capita Annual all payer healthcare spending per person $8,402**

* Source: Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey, 2010. Corrected May 2014.
** Source: Center for Medicare and Medicaid Services, Health Expenditure Data, Health Expenditures by State of Residence; 2010. Corrected May 2014.

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Next Steps

As described in the 2011 strategy, the National Quality Strategy is an adaptable and evolving guide to improve health, improve quality of care and lower costs for all Americans. As its implementation proceeds, the National Quality Strategy will be periodically refined, based on lessons learned in the public and private sectors, emerging best practices, new research findings, and the changing needs of the Nation. Annual reports to Congress and the American people will include updates on the National Quality Strategy and the Nation's progress in meeting the three aims of better care, healthy people/healthy communities, and making quality care more affordable and the progress on the six priorities.

In particular, the next version of the National Quality Strategy will include aspirational targets for a greater number of the key measures identified in this year's report that will serve as markers of progress for the six priority areas. In addition, further partnership between the public and private sectors will be convened over the next year to develop and validate additional measures in areas where the National Priorities Partnership found current efforts to be lacking, such as care coordination and affordable care.

As mentioned previously in this report, the National Priorities Partnership's input to the Secretary on priorities for the National Quality Strategy included three categories of strategic opportunities for driving improvement across all dimensions of the National Quality Strategy, namely: 1) A national strategy for data collection, measurement, and reporting; 2) Development of organizational infrastructure at the community level that assumes responsibility for improvement efforts; and 3) Ongoing payment and delivery system reforms. The National Quality Strategy will be a catalyst for action in each of these three areas by engaging stakeholders to identify next steps for progress.


3 This survey measure provides patient-centered perspectives on coordination of hospital discharge care.
4http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/QualityMeasurementImpactReports.html
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6http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69885 Exit Disclaimer
7http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2011_StateReporttoCongress.pdf (PDF Help)
8 The core set of measures can be viewed at http://www.ahrq.gov/news/events/nac/reports/nacqm11
9 See http://www.cdc.gov/winnablebattles for more information.
10 The full strategy is available at http://jfs.ohio.gov/ohp/infodata/documents/OHMedQltyStrag09_11.pdf. Exit Disclaimer (PDF Help)
11 http://www.qualityforum.org/Setting_Priorities/NPP/Input_into_the_National_Quality_Strategy.aspx Exit Disclaimer
12 National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination. Centers for Disease Control and Prevention (CDC), Division of Healthcare Quality Promotion (DHQP), 2011.


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