Behavioral Health Measures Development and Inpatient and Outpatient Measure Maintenance

2019 – 2024

Project Overview


The primary objectives of this project are to (1) develop measures for use in the Inpatient Psychiatric Facility Quality Reporting Program (IPFQR) and (2) to maintain quality measures for five CMS hospital quality programs: IPFQR, Promoting Interoperability (PI), Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), and Ambulatory Surgical Center Quality Reporting (ASCQR).

Project Motivation

CMS is working to shift the basis of payment away from the volume of care delivered towards the value of care. Mathematica plays a key role in this effort by helping CMS develop, test and implement valid and reliable clinical quality measures that rely on data collected over the course of care delivery. For the inpatient psychiatric facility setting, Mathematica supports CMS in developing and implementing patient-reported outcome performance measures (PRO-PMs). Under this contract, Mathematica also works with CMS to maintain a set of hospital-based pay-for-reporting measures.

Partners in Progress

  • Lantana Consulting Group
  • The Joint Commission (TJC)
  • Telligen
  • HealthCare Dynamics International (HCDI)

Prepared For

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services

Mathematica has played a key role in helping CMS’s Center for Clinical Standards and Quality (CCSQ) further its goal of shifting the basis of payment from volume to value, working with CCSQ to develop, test, implement, and maintain measures used in hospital-based quality reporting programs since 2014.
This project helps CCSQ develop measures for use in the Inpatient Psychiatric Facility Quality Reporting Program (IPFQR) and maintain quality measures across five pay-for-reporting programs for hospitals, outpatient hospital departments, and surgery centers. For IPFQR, Mathematica develops measures to assess quality of care provided to patients in IPFs. Mathematica reviews IPFQR measure concepts to identify those that are viable and supported by a strong evidence base. To develop those promising concepts into fully specified measures that are meaningful to patients and payers, Mathematica incorporates human-centered design approaches, balanced with careful examination of the evidence and rigorous testing. The Mathematica team also maintains and annually updates quality measures used in hospital-based pay-for-reporting programs. These include IPFQR, Promoting Interoperability, Hospital Inpatient Quality Reporting, Hospital Outpatient Quality Reporting, and Ambulatory Surgical Center Quality Reporting. The measures include claims-based, chart-abstracted, and electronic clinical quality measures (eCQMs). The National Quality Forum endorsed five of these measures in the first year of the project. Mathematica and its partners effectively implement new and evolving eCQM standards and actively seek review and feedback from implementers and vendors to continually improve the specifications.

Related Staff

Kirsten  Barrett

Kirsten Barrett

Principal Researcher

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Cindy  Cullen

Cindy Cullen

Senior Director, Business Development

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Samuel Simon

Samuel Simon

Senior Director

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