Measuring What Matters: CMS Introduces a New Methodology for “Topped Out” Measures

Performance measures are tools that help us measure or quantify health care processes, outcomes, patient perceptions and organizational structure. CMS implements these measures to ensure quality health care for Medicare Beneficiaries and incentivize transparency through public reporting, as well as high value care compared with incentives for volume of care received. In the physician setting, the use of performance measures aims to decrease variations in care, while achieving optimal outcomes and decreasing costs.

Recently, CMS has proposed to remove several measures they have deemed “topped out.” That is, for these measures, overall performance is so high (near 100 percent) that CMS denotes that the measures are no longer meaningful to collect and report. In the Inpatient Prospective Payment Systems (IPPS) final rule for Calendar Year (CY) 2015 released on Aug. 4, CMS finalized its proposal to remove 18 measures from the Inpatient Quality Reporting (IQR) Program due to their “topped out” status.

CMS’ finalized change involved two new criteria. In order to demonstrate “topped out” status, measures: 1) should show statistically indistinguishable performance at the 75th and 90th percentiles; and 2) should also have a truncated coefficient of variation ≤0.10. CMS maintained that 10 of the 18 retired measures be included as voluntary submissions within the EHR-reporting program to facilitate monitoring for declines in performance. CMS has similarly proposed removal of “topped out” measures from quality programs for other settings, including for the Physician Quality Reporting System (PQRS).

Stakeholder Perspective

Stakeholder response to CMS’ approach to remove topped out measures has been mixed. Several stakeholders have acknowledged that a more frequent review of performance measures is needed to determine if the burden associated with data collection/reporting continues to be warranted, given the value of the information provided by the measures. The National Quality Forum (NQF) has adopted a “reserve” endorsement status to categorize measures where overall performance was found to be high, although NQF has not adopted a specific threshold to determine high performance. While many professional societies and associations have indicated their approval of CMS’ approach to retiring measures that are found to be “topped out,” CMS noted that some organizations were in disagreement with their proposal to retire key standard of care measures.

In general, stakeholders believe applying a “topped out” approach reflects more realistic performance benchmarks for determining when an appropriate threshold of provider performance has been reached in a variety of group practices. In a public comment letter released June 30, 2014, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) expressed support of CMS’ efforts to minimize the reporting burden on providers by removing “topped out” measures from the Hospital IQR program. They encouraged CMS to retain “topped out” measures as voluntary electronic clinical quality measures, where possible, to provide hospitals with more flexible reporting options and to ensure these metrics can still be tracked by those facilities that wish to do so.

What are the concerns?

Removal of existing “topped out” measures provides CMS with an opportunity to include new measures, particularly more meaningful measures that address processes and/or outcomes that meet gaps in the current system. However, few of these types of measures, which are often challenging to develop, currently exist. In addition, because the “topped out” performance measures are processes that are important to patient care, CMS must monitor these voluntary measures to ensure that there is not a decline in performance over time. One measure CMS has recently decided to remove due to its “topped out” status is the Joint Commission’s Acute Myocardial Infarction (AMI) “Aspirin at Arrival” measure. High rates for performance on this measure indicate that the practice of providing aspirin at arrival for AMI patients has become the standard of care, and that this measure is therefore no longer needed. In the final IPPS rule, CMS noted that this measure would be collected voluntarily via the electronic health record which may result in an inaccurate assessment of performance.

In addition, for quality programs such as PQRS, CMS is determining which measures are “topped out” when overall participation is somewhat low—in 2012, CMS estimated participation in the program to be 36 percent of eligible providers. Performance for these measures may change over time as participation nears 100 percent. Alternatively, CMS might consider waiting until measures have been “topped out” for a few years.

As both public and private reporting initiatives continue to expand, efforts to acknowledge the significant burden of data collection for these programs and ensure that they continue to “measure what matters” for patient outcomes are critical. CMS is likely to continue to identify measures that no longer provide meaningful information to stakeholders, including those measures found to be “topped out.” Over time, regular monitoring for unintended consequences will be required to ensure that quality of care is maintained for areas where high performance has been observed.

Kristi Mitchell is the Senior Vice President at Avalere Health


  1. Joint Commission Comments: http://www.regulations.gov/contentStreamer?objectId=09000064817774f6&disposition=attachment&contentType=pdf
  2. American Hospital Association Comments: http://www.regulations.gov/contentStreamer?objectId=090000648176bc8e&disposition=attachment&contentType=pdf
  3. FY2014 IPPS Propose Rule: https://www.federalregister.gov/articles/2014/05/15/2014-10067/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the#h-257
  4. FY2015 IPPS Final Rule: http://www.ofr.gov/OFRUpload/OFRData/2014-18545_PI.pdf
  1. Hospital VBP Program Rule (May 2011): https://www.federalregister.gov/articles/2011/05/06/2011-10568/medicare-program-hospital-inpatient-value-based-purchasing-program
  2. Hospital VBP Program Rule (January 2011): https://www.federalregister.gov/articles/2011/01/13/2011-454/medicare-program-hospital-inpatient-value-based-purchasing-program
  3. NQF Reserved Status Proposal: http://www.qualityforum.org/docs/Reserve_Endorsement_Status.aspx
  4. American Society of Health-System Pharmacists:http://www.ashp.org/DocLibrary/Advocacy/CMS-1607-P.pdf


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