Monday, March 4, 2024

Nerd Note: Medicare Law Remarks on Costs of Quality Measures, CPT Codes

Header.  Congress renews funding for a quality measures institute.  From that springboard, we discuss pricing and cost policy for both quality measures and the CPT.


As discussed in this blog in August 2023, HHS transferred the longstanding quality measures contract from National Qualify Forum (NQF) to Battelle, where it is now titled, the PQP Partnership for Quality Measurement.

Here's some trivia on the topic.

Where's the Quality Institute in Statute?

The relevant part of the Medicare statute is SSA 1890, "Contract with Consensus Based Entity."

Do Quality Forums Report Have to Congress and Public?

NQF's last report to Congress (for CY2022) weighed in at 92 pages and appeared in March 2023, here:

I would guess the quality report to Congress for March or April 2024, representing CY2023, will probably come from Battelle/PQP.

Funding for Quality Measures?

In the March 2024 bill to keep the government running, PQP was given $20M for one period and $9M for another period.

So NQF/PQP have a funded monopoly on quality measures.   In contrast, the AMA has a "monopoly" so to speak on CPT coding for physician, imaging, and lab services, but it is not funded (it is self-funded through sales). It's at 45 CFR 161.1002.   

Costs and Pricing of Quality Measures and Codes - Compared

Regarding the quality forum costs, SSA 1890(c)(7) remarks,

  • Membership fees.—If the entity requires a membership fee for participation in the functions of the entity, such fees shall be reasonable and adjusted based on the capacity of the potential member to pay the fee. In no case shall membership fees pose a barrier to the participation of individuals or groups with low or nominal resources to participate in the functions of the entity.

Regarding costs of coding entities like the CPT, the language isn't in statute (162.1000ff) but it was included in the original rulemaking on August 17, 2000 (65 FR 50324):

  • Under HIPAA, the Secretary has the authority to select existing code sets developed by either private or public entities and is not precluded from selecting proprietary code sets. The Secretary is required to ensure that all standard code sets are updated as needed and that there are efficient, low cost mechanisms for distribution (including electronic distribution) of the code sets and their updates. 
  • Free distribution of standard code sets is not required by the statute. 
  • We have obtained some clarification from the developers of these code sets about the pricing structure and mechanisms for publishing the pricing structure that will be in place when the initial standards are implemented. 
  • The existence of efficient, low-cost distribution mechanisms will affect future decisions regarding changes or additions to the code sets designated as standards/