VALUE IN ONCOLOGY
Measuring Value in Healthcare to Improve Quality By Chase Doyle
M
edicare is poised to incorpo rate new quality metrics as a guide for payments. At ASH 2015, Helen Burstin, MD, MPH, Chief Scientific Officer, National Quality Forum, Washington, DC, discussed the need for measures and reporting sys tems that reflect patient care and care coordination. “The purpose of measurement is to improve healthcare quality,” said Dr Burstin. “We want to focus on mea sures that provide value for both pa tients and oncologists and may ulti mately drive systematic change.” To this end, Dr Burstin and col leagues considered the use of measure ments based on episode of care rather than costs reflected in individual claims. “How do you move from a population at risk all the way through the acute management of illness to postacute care and secondary prevention?” Dr Burstin asked. “What kind of outcome measures could be used to describe that space?” Although measures such as func tional status, quality of life, costs, and advance care planning are a compo nent of that, a more comprehensive set of measures is needed, according to Dr Burstin. At the same time, as consum ers and purchasers seek out better data, tensions between system-level mea surement and individual assessment arise. Metrics are therefore needed for different specialists and settings. Hematology-Specific Measures
Hematology-specific measures can be
“The purpose of measurement is to improve healthcare quality. We want to focus on measures that provide value for both patients and oncologists.” —Helen Burstin, MD, MPH
divided into the following categories: • Testing (eg, cytogenetic testing on bone marrow) • Treatment and documentation (eg, the pathology report in the chart confirming diagnosis and a docu mented plan for chemotherapy) • Symptom and function assessment. Health behaviors, such as smoking status, can also be reported as a cost-cutting measure. Also important are the very significant set of measures for advanced directives: hospice en
rollment, death from cancer in the in tensive care unit, and chemotherapy administered in the last 2 weeks of life. Although such measures are a good start, Dr Burstin believes the key to measuring value is moving away from process measures toward outcome measures. “Outcomes are the reasons patients seek care, and why providers deliver care,” she said. “Outcomes are integra tive, reflecting the result of all care pro vided over a particular time period. In addition, measuring performance on out comes encourages a ‘systems approach’ to providing and improving care rather than narrow process measures.” In addition, “measuring outcomes encourages innovation in identifying ways to improve outcomes that might not previously have been considered modifiable,” she added. An underutilized example of this is patient-reported outcomes. “Researchers have developed an elegant set of tools for patients,” said Dr Burstin. “These are well-validated patient-level instruments.” And yet, there are challenges to using patient-reported outcomes for account ability and performance improvement, she said, because little is known about how to aggregate this information. Unintended Consequences
Despite the upside to measuring out comes, persistent measurement gaps have been identified. “There is a real concern around potential for unin tended consequences,” Dr Burstin cau
tioned. “We don’t want to be incentiv izing bad medical decisions.” There are also challenges with ac countability, as patient selection can lead to significant differences across physicians or hospitals. Furthermore, outcomes reflect a variety of factors, not all related to the care provided. “Some of these factors are patient-related,” she said. “Some of which are modifiable, and some of which are not.” These factors include genetics, de mographic characteristics, clinical fac tors, psychosocial factors, socioeco nomic, and environmental factors. There are also health-related behaviors and activities (eg, tobacco, diet) to consider. Finally, risk adjustments can be made for socioeconomic status, too, although this remains controversial. Discussing her study, she said, “There was a huge dichotomy of opin ion between those who thought adjust ment for socioeconomic status was necessary for the sake of comparative performance, and those who thought it would mask disparities and not move us forward.” While acknowledging that the move toward more episode-based, valuebased purchasing is not going to be easy, Dr Burstin was encouraged by support from multiple stakeholders. “We are hearing a great deal of in terest, not just from the public side, but from the commercial side, and health clinic world, as well,” she con cluded. “It’s a move that needs to be made.” s
Redesigning the Payment Model... Continued from page 10 ing a sustainable payment model for acute leukemia challenging. The Episode-of-Care Payment Model
Defined as 6 months of care, an episode of care begins with a new diagnosis, re lapse, or disease progression. By assuming all risk for direct care costs, readmission, emergency department visits, and admis sions for unrelated medical conditions, the goal is to develop more effective care coordination, incentivize appropriate care, and improve access to beneficiaries. However, financial risk transfer works best when there is sufficient clinical volume to amortize risk, and providers have significant control over thera py-related complications. “The absence of a robust set of clini
The treatment of acute leukemia is rapidly evolving as a result of a growing understanding of cytogenetic, molecular, and genomic risk factors. “There are many patients for whom there is no clear standard of care.” —Joseph Alvarnas, MD
cal care data may severely hamstring the clinical effectiveness and financial sustainability of this payment model,” said Dr Alvarnas. “An alternative ap proach, like a shared-savings model, may incentivize more effective acute leukemia care models.” Toward Value-Based Care Delivery in Hematology
Regardless of the payment model’s
final form, we must move from a mind set of cost-insensitive care delivery to ward value-based care delivery, accord ing to Dr Alvarnas. “We need integrated care delivery models that provide care most effi ciently at the lowest-priced setting, and we need to look for opportunities for increasing efficiency in care deliv ery—reducing duplicative testing, im aging, and non–value-added care,” said
Dr Alvarnas. In addition, hematologists need to tackle the issue of care mismatches at the end of life and ensure that patients are managed consistently, he said. Finally, consistently producing and reporting transparent care outcomes data is critical to ensure that economic incentives align with the most effective and appropriate care. “Any care delivery economic model needs to be re-evaluated and revised it eratively based upon the provider hav ing a thorough understanding of patient clinical process, outcomes, and eco nomic data,” Dr Alvarnas concluded. “By realizing the profound complexity of this endeavor, we can partner more effectively with payers and government to create this system.”—CD s
FEBRUARY 2016
11
Measuring Value in Healthcare to Improve Quality By Chase Doyle
M
edicare is poised to incorpo rate new quality metrics as a guide for payments. At ASH 2015, Helen Burstin, MD, MPH, Chief Scientific Officer, National Quality Forum, Washington, DC, discussed the need for measures and reporting sys tems that reflect patient care and care coordination. “The purpose of measurement is to improve healthcare quality,” said Dr Burstin. “We want to focus on mea sures that provide value for both pa tients and oncologists and may ulti mately drive systematic change.” To this end, Dr Burstin and col leagues considered the use of measure ments based on episode of care rather than costs reflected in individual claims. “How do you move from a population at risk all the way through the acute management of illness to postacute care and secondary prevention?” Dr Burstin asked. “What kind of outcome measures could be used to describe that space?” Although measures such as func tional status, quality of life, costs, and advance care planning are a compo nent of that, a more comprehensive set of measures is needed, according to Dr Burstin. At the same time, as consum ers and purchasers seek out better data, tensions between system-level mea surement and individual assessment arise. Metrics are therefore needed for different specialists and settings. Hematology-Specific Measures
Hematology-specific measures can be
“The purpose of measurement is to improve healthcare quality. We want to focus on measures that provide value for both patients and oncologists.” —Helen Burstin, MD, MPH
divided into the following categories: • Testing (eg, cytogenetic testing on bone marrow) • Treatment and documentation (eg, the pathology report in the chart confirming diagnosis and a docu mented plan for chemotherapy) • Symptom and function assessment. Health behaviors, such as smoking status, can also be reported as a cost-cutting measure. Also important are the very significant set of measures for advanced directives: hospice en
rollment, death from cancer in the in tensive care unit, and chemotherapy administered in the last 2 weeks of life. Although such measures are a good start, Dr Burstin believes the key to measuring value is moving away from process measures toward outcome measures. “Outcomes are the reasons patients seek care, and why providers deliver care,” she said. “Outcomes are integra tive, reflecting the result of all care pro vided over a particular time period. In addition, measuring performance on out comes encourages a ‘systems approach’ to providing and improving care rather than narrow process measures.” In addition, “measuring outcomes encourages innovation in identifying ways to improve outcomes that might not previously have been considered modifiable,” she added. An underutilized example of this is patient-reported outcomes. “Researchers have developed an elegant set of tools for patients,” said Dr Burstin. “These are well-validated patient-level instruments.” And yet, there are challenges to using patient-reported outcomes for account ability and performance improvement, she said, because little is known about how to aggregate this information. Unintended Consequences
Despite the upside to measuring out comes, persistent measurement gaps have been identified. “There is a real concern around potential for unin tended consequences,” Dr Burstin cau
tioned. “We don’t want to be incentiv izing bad medical decisions.” There are also challenges with ac countability, as patient selection can lead to significant differences across physicians or hospitals. Furthermore, outcomes reflect a variety of factors, not all related to the care provided. “Some of these factors are patient-related,” she said. “Some of which are modifiable, and some of which are not.” These factors include genetics, de mographic characteristics, clinical fac tors, psychosocial factors, socioeco nomic, and environmental factors. There are also health-related behaviors and activities (eg, tobacco, diet) to consider. Finally, risk adjustments can be made for socioeconomic status, too, although this remains controversial. Discussing her study, she said, “There was a huge dichotomy of opin ion between those who thought adjust ment for socioeconomic status was necessary for the sake of comparative performance, and those who thought it would mask disparities and not move us forward.” While acknowledging that the move toward more episode-based, valuebased purchasing is not going to be easy, Dr Burstin was encouraged by support from multiple stakeholders. “We are hearing a great deal of in terest, not just from the public side, but from the commercial side, and health clinic world, as well,” she con cluded. “It’s a move that needs to be made.” s
Redesigning the Payment Model... Continued from page 10 ing a sustainable payment model for acute leukemia challenging. The Episode-of-Care Payment Model
Defined as 6 months of care, an episode of care begins with a new diagnosis, re lapse, or disease progression. By assuming all risk for direct care costs, readmission, emergency department visits, and admis sions for unrelated medical conditions, the goal is to develop more effective care coordination, incentivize appropriate care, and improve access to beneficiaries. However, financial risk transfer works best when there is sufficient clinical volume to amortize risk, and providers have significant control over thera py-related complications. “The absence of a robust set of clini
The treatment of acute leukemia is rapidly evolving as a result of a growing understanding of cytogenetic, molecular, and genomic risk factors. “There are many patients for whom there is no clear standard of care.” —Joseph Alvarnas, MD
cal care data may severely hamstring the clinical effectiveness and financial sustainability of this payment model,” said Dr Alvarnas. “An alternative ap proach, like a shared-savings model, may incentivize more effective acute leukemia care models.” Toward Value-Based Care Delivery in Hematology
Regardless of the payment model’s
final form, we must move from a mind set of cost-insensitive care delivery to ward value-based care delivery, accord ing to Dr Alvarnas. “We need integrated care delivery models that provide care most effi ciently at the lowest-priced setting, and we need to look for opportunities for increasing efficiency in care deliv ery—reducing duplicative testing, im aging, and non–value-added care,” said
Dr Alvarnas. In addition, hematologists need to tackle the issue of care mismatches at the end of life and ensure that patients are managed consistently, he said. Finally, consistently producing and reporting transparent care outcomes data is critical to ensure that economic incentives align with the most effective and appropriate care. “Any care delivery economic model needs to be re-evaluated and revised it eratively based upon the provider hav ing a thorough understanding of patient clinical process, outcomes, and eco nomic data,” Dr Alvarnas concluded. “By realizing the profound complexity of this endeavor, we can partner more effectively with payers and government to create this system.”—CD s
FEBRUARY 2016
11
