The Obama administration earlier this week announced a not-so radical idea: Medicare, the massive health-care program for seniors, should do a much better job of paying doctors and hospitals for quality, not quantity, when it comes to care. Instead of paying a flat fee for each service, the administration said by 2018 it wants half of Medicare payments to hospitals and care providers to be calculated based on whether patients see better results.

Because Medicare is such a huge part of overallhealth care spending, the hope is that these changes will trickle outto doctors offices and hospitals across the country, reshapinghoweveryone gets treated. And many of these same efforts are already under way in the private sector.

On its face, it sounds reasonable enough. Who doesn't want to cut waste in America's $2.9 trillion health-care system and improve the kind of care that patients get?

But actually determining the quality of this care is tough business.

The financial stakes are high for the health-care industry and patients. For example, hospitals can face as much as a 2 percent pay cut from Medicare this year if they have especially high rates of patients returning within 30 days being discharged. The tricky thing there is that higher readmission rates dont necessarily indicate a hospital isnt as good there are other factors to consider, including where the hospital's located and the mix of patients.

The number of ways that quality is measured is vast. By one count, 33 different care programs within Medicare used a combined 1,676 reporting measures last year, and about half of those measures were unique to just one program. Another 2013 study of 23 commercial health plans found 546 distinct quality measures, with very little overlap with reporting requirements in federal programs.

There's one group at the center of all this trying to make better sense of how to define quality, and how to give doctors, hospitals and other health-care providers the right financial incentives to pursue a more rational health-care systems. It's known as the National Quality Forum, a Washington-based nonprofit pulling together a wide range of stakeholders to reach greater consensus on how to get the best value from the country's health-care dollars.

For the last four years, the NQF has convened expert panels to make recommendations on how to measure quality across 20 Medicare initiatives that reward providers for delivering better care. This includes programs like the billions of dollars toward the adoption of electronic health records, programs rewarding hospitals for patient satisfaction, new incentives for providers to group together to deliver care on a budget, and more.

The group, under contract with the federal Centers for Medicare and Medicaid Services, released 2015 recommendations Friday after receiving 1,100 comments on more than 200 possible reporting measures, which include wide-ranging items from how often patients fall, nurse staffing levels, and whether patients receive follow-up care. The vast majority of these quality-based Medicare payment programs are just a few years old, so everyones still tinkering with the formula based on the best available evidence.

This year's recommendations reflect that there needs to be "a much deeper bench" of quality metrics amid the greater shift toward care emphasizing quality, said NQF president and chief executive Christine Cassel. "You can't do value-based purchasing unless you define value," she said. There's also a major effort to better understand how patients respond to the treatments they receive and to better align the varying quality measures across the federal programs, as well as with the private sector.

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