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CMS leaders propose ‘Universal Foundation’ for health program measures


Adult, youth criteria aim to support care for 150 million people across nation.

Federal health care programs would benefit from a shared set of standards to measure improvements for adults and children, say leaders within the U.S. Centers for Medicare & Medicaid Services (CMS).

A new “Universal Foundation” would serve as a core set of quality measures that align across programs that currently have their own criteria to assess individual physicians and clinicians or health care settings such as hospitals, skilled nursing facilities, insurers, or accountable care organizations.

“Our intention is that the Universal Foundation will eventually include selected measures for assessing quality along a person’s care journey – from infancy to adulthood – and for important care events, such as pregnancy and end-of-life care,” CMS leaders said in an article last month. “Aligning Quality Measures across CMS – The Universal Foundation,” was published Feb. 1 in the New England Journal of Medicine.

They noted the health care quality measurement movement began more than 20 years ago, for good and bad. Health care has transparent benchmarks for quality, but lack of alignment contributes to challenges in prioritizing outcomes that are meaningful for patients.

CMS has more than 20 quality programs, each with its own set of measures to hold providers accountable. Some of the measures are consistent, some are not.

“We believe aligning measures to focus provider attention and drive quality improvement and care transformation will catalyze efforts in this area,” the authors said.

For the record

The Universal Foundation was included in the Calendar Year (CY) 2024 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. The notice said the Universal Foundation “will support efforts to ensure high quality care for more than 150 million Americans covered by our programs and serve as an alignment standard for rest of the health care system.”

There are five goals for the preliminary measures, numbering 10 for adults and 11 for pediatric care.

Five goals

  • The Universal Foundation has five goals to better understand what drives quality and equity improvement and what does not. It will:
  • Focus provider attention.
  • Reduce provider burden.
  • Allow for consistent stratification of measures to identify disparities in care.
  • Accelerate the transition to interoperable, digital quality measures.
  • Allow for cross-comparisons across quality and value-based care programs.


Among the preliminary Universal Foundation measures for adults:

  • Wellness and prevention: Colorectal cancer screening, breast cancer screening, adult immunization status.
  • Chronic conditions: Controlling high blood pressure and hemoglobin A1C poor control.
  • Behavioral health: Screening for depression and follow-up plan; initiating and engagement of substance use disorder treatment.
  • Seamless care coordination: Plan all-cause readmissions or all-cause hospital readmissions.
  • Person-centered care: Consumer assessment of health care providers and systems overall rating measures.
  • Equity: Screening for social drivers of health.


Among the preliminary Universal Foundation measures for youths:

  • Wellness and prevention: Well-child visits; immunization; with assessment and counseling for nutrition and physical activity; oral evaluation and dental services
  • Chronic conditions: Asthma medication ratio
  • Behavioral health: screening for depression and follow-up plans; follow-ups for hospitalization for mental illness or emergency department visits for substance use; first-line psychosocial care for children and adolescents on antipsychotics; follow-up care for children prescribed attention deficit-hyperactivity disorder medication
  • Person-centered care: Consumer assessment of healthcare Providers and Systems overall rating measures

Foundation will evolve

The authors said the Universal Foundation will identify CMS’ priority areas and reveal gaps in measurements. For example, patient safety is a top priority and there are well-developed measures in hospitals, but there is no standard widely used in ambulatory settings.

The Universal Foundation will evolve over time, with standards added or removed as needed.

The authors acknowledged they need buy-in from all of health care: physicians, clinicians, provider organizations, insurers, community groups, state and local governments, and patients.

The authors of the NEJM article are: Douglas B. Jacobs, MD, MPH, chief transformation officer; Michelle Schreiber, MD, deputy director for quality and value in the Center for Clinical Standards & Quality; Meena Seshamani, MD, PhD, deputy administrator and director of the Center for Medicare; Daniel Tsai, deputy administrator and director in the Center for Medicaid & CHIP Services; Elizabeth Fowler, deputy administrator and director of the Center for Medicare & Medicaid Innovation; and Lee A. Fleisher, MD, chief medical officer and director of the Center for Clinical Standards & Quality.

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