VALUE IN ONCOLOGY
Value-Based Purchasing: Implications for Hematology By Chase Doyle
M
edicare has initiated several programs in the past decade to encourage value, but ques tions remain regarding their effective ness. At ASH 2015, Andrew Ryan, PhD, MA, Associate Professor of Health Management and Policy, Uni versity of Michigan School of Public Health, Ann Arbor, addressed the im plications of using financial incentives to drive care quality and reduce cost. “Many quality indicators are moving in the right direction,” said Dr Ryan. “At the same time, we don’t see a lot of evidence that these programs are associ ated with incremental benefits,” he said. “The one exception is the Hospital Readmissions Reduction Program, which does seem to be reducing read missions, although we have potentially offsetting, unintended consequences that need to be weighed against those benefits,” Dr Ryan added.
PQRS, most (65.4%) are related to clin ical process performance (ie, delivering the right care to the right patient at the right time), according to Dr Ryan. “We’ve gone from a system that awards physicians for participating in PQRS to now penalizing physicians for not reporting in PQRS,” he said. De spite the increase in performance mea sures (and penalties), doubt about their effectiveness remains. Value-Based Purchasing
“Are hematologists going to be able to fit comfortably in these new groups, or not? And how should drug prescribing and drug costs be accommodated in valuebased payment systems?”
What Do We Mean by “Value”?
Dr Ryan said that the essence of value can be defined simply as the ratio of quality to cost. Although cost is rela tively straightforward, quality can be a more amorphous concept, comprising clinical performance, patient experi ence, and patient outcomes. “Quality means a lot of different things to a lot of different people,” he observed. The Centers for Medicare & Medic aid Services (CMS) has implemented several programs to foster value in
—Andrew Ryan, PhD, MA
Medicare over the years, including the Premier Hospital Quality Incentive Demonstration, Hospital Value-Based Purchasing, accountable care organiza tions, the Medicare Advantage Quality Bonus Payment Demonstration, the Physician Quality Reporting System (PQRS), and the Physician Value-Based Payment Modifier. Of the 280 quality measures in the
“Since we’ve started reporting for hospitals in 2005, we’ve seen a steady increase in performance and clinical process measures,” said Dr Ryan. “The Hospital Readmissions Reduction Program has seemingly improved pro cess performance and has reduced readmissions.” Although an increase in clinical process performance was observed over time, Dr Ryan reported no improve ment in patient outcomes associated with the start of the program. “Public reporting has not improved outcomes or impacted consumer choice,” he said. “The effect of incen tives on process in Premier demo atten uated over time, and there were no im provements in mortality outcomes that were associated with this program.” In addition, the Hospital Value- Based Purchasing program did not im prove clinical outcomes and patient experience in its first year.
Even more troubling is the evidence that decreases in readmissions may be driven by hospitals classifying patients in other units rather than having pa tients readmitted to patient wards. “There is a real question about the validity of performance measures being used,” he said. “We’re just not sure how valid these claims-based outcome measures really are.” Finally, there is concern that perfor mance incentive measuring could lead to further disparities in payments. Al though CMS is aware of the problem and is trying to adjust it, hospitals car ing for more difficult or complicated patients, for example, tend to do worse in these measures, Dr Ryan suggested. Implications for Hematologists
Starting in 2018, when the Merit- Based Incentive Payment System will take effect, physicians are going to have to choose whether or not to align themselves with accountable groups, said Dr Ryan. “Are hematologists going to be able to fit comfortably in these new groups, or not? And how should drug pre scribing and drug costs be accommo dated in value-based payment systems?” he asked. “This is a big part of hematologic care,” Dr Ryan concluded. “We need to address these issues moving forward to make sure that the measures in PQRS are taking us where we want to go.” s
G
iven the high cost of care for acute leukemia, innovative pay ment strategies that reward lon gitudinal care and create economic in centives for data-driven care delivery are needed, according to Joseph Alvarnas, MD, Director of Value-Based Analytics, and Associate Clinical Professor of He matology and Hematopoietic Cell Trans plantation, City of Hope, Duarte, CA. At ASH 2015, Dr Alvarnas discussed the episode-of-care payment model, em phasizing the importance of realigning infrastructure to support a continuum of care instead of restructuring healthcare based on the next intervention. “Hematologists need to ensure that their care delivery model is based upon achieving ‘systemness’ in care,” said Dr Alvarnas, “which means both seamless
© American Society of Hematology. All rights reserved.
Redesigning the Payment Model for Acute Leukemia: Benefits and Challenges of the Episode-of-Care Model “While the sensibilities behind the episode-of-care payment model are correct, it is unclear whether this particular financial model is suitable for acute leukemia.”
multidisciplinary care coordination and transparency and consistency of care processes. The entire system must be aligned around patients’ needs.” High Variability of Cost and Complications in Acute Leukemia
“While the sensibilities behind the episode-of-care payment model are cor rect,” he added, “it is unclear whether
—Joseph Alvarnas, MD
this particular financial model is suit able for acute leukemia.” Acute leukemia represents only 1.7% of all cancer diagnoses but accounts for nearly 5% of all cancer spending, total ing $5.4 billion annually, said Dr Alvar nas. At the same time, on a case-by-case basis, many studies have shown high interpatient variability in costs. “We’re not really sure how much it
costs to treat acute leukemia effectively, due to low disease incidence,” said Dr Alvarnas, noting that cost estimates fluc tuate from an average of $41,594 to $77,769 for patients who receive chemo therapy to $128,630 for patients whose disease relapses. “Predictions of costs are unlikely to achieve statistical significance without wide margins,” he observed. In addition, the treatment of acute leukemia is rapidly evolving as a result of a growing understanding of cytoge netic, molecular, and genomic risk fac tors. “There are many patients for whom there is no clear standard of care,” said Dr Alvarnas. Furthermore, escalating pharmaceu tical costs, particularly targeted agents, and a high variability of complications that cannot be prevented, make build Continued on page 11
10
FEBRUARY 2016
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
Value-Based Purchasing: Implications for Hematology By Chase Doyle
M
edicare has initiated several programs in the past decade to encourage value, but ques tions remain regarding their effective ness. At ASH 2015, Andrew Ryan, PhD, MA, Associate Professor of Health Management and Policy, Uni versity of Michigan School of Public Health, Ann Arbor, addressed the im plications of using financial incentives to drive care quality and reduce cost. “Many quality indicators are moving in the right direction,” said Dr Ryan. “At the same time, we don’t see a lot of evidence that these programs are associ ated with incremental benefits,” he said. “The one exception is the Hospital Readmissions Reduction Program, which does seem to be reducing read missions, although we have potentially offsetting, unintended consequences that need to be weighed against those benefits,” Dr Ryan added.
PQRS, most (65.4%) are related to clin ical process performance (ie, delivering the right care to the right patient at the right time), according to Dr Ryan. “We’ve gone from a system that awards physicians for participating in PQRS to now penalizing physicians for not reporting in PQRS,” he said. De spite the increase in performance mea sures (and penalties), doubt about their effectiveness remains. Value-Based Purchasing
“Are hematologists going to be able to fit comfortably in these new groups, or not? And how should drug prescribing and drug costs be accommodated in valuebased payment systems?”
What Do We Mean by “Value”?
Dr Ryan said that the essence of value can be defined simply as the ratio of quality to cost. Although cost is rela tively straightforward, quality can be a more amorphous concept, comprising clinical performance, patient experi ence, and patient outcomes. “Quality means a lot of different things to a lot of different people,” he observed. The Centers for Medicare & Medic aid Services (CMS) has implemented several programs to foster value in
—Andrew Ryan, PhD, MA
Medicare over the years, including the Premier Hospital Quality Incentive Demonstration, Hospital Value-Based Purchasing, accountable care organiza tions, the Medicare Advantage Quality Bonus Payment Demonstration, the Physician Quality Reporting System (PQRS), and the Physician Value-Based Payment Modifier. Of the 280 quality measures in the
“Since we’ve started reporting for hospitals in 2005, we’ve seen a steady increase in performance and clinical process measures,” said Dr Ryan. “The Hospital Readmissions Reduction Program has seemingly improved pro cess performance and has reduced readmissions.” Although an increase in clinical process performance was observed over time, Dr Ryan reported no improve ment in patient outcomes associated with the start of the program. “Public reporting has not improved outcomes or impacted consumer choice,” he said. “The effect of incen tives on process in Premier demo atten uated over time, and there were no im provements in mortality outcomes that were associated with this program.” In addition, the Hospital Value- Based Purchasing program did not im prove clinical outcomes and patient experience in its first year.
Even more troubling is the evidence that decreases in readmissions may be driven by hospitals classifying patients in other units rather than having pa tients readmitted to patient wards. “There is a real question about the validity of performance measures being used,” he said. “We’re just not sure how valid these claims-based outcome measures really are.” Finally, there is concern that perfor mance incentive measuring could lead to further disparities in payments. Al though CMS is aware of the problem and is trying to adjust it, hospitals car ing for more difficult or complicated patients, for example, tend to do worse in these measures, Dr Ryan suggested. Implications for Hematologists
Starting in 2018, when the Merit- Based Incentive Payment System will take effect, physicians are going to have to choose whether or not to align themselves with accountable groups, said Dr Ryan. “Are hematologists going to be able to fit comfortably in these new groups, or not? And how should drug pre scribing and drug costs be accommo dated in value-based payment systems?” he asked. “This is a big part of hematologic care,” Dr Ryan concluded. “We need to address these issues moving forward to make sure that the measures in PQRS are taking us where we want to go.” s
G
iven the high cost of care for acute leukemia, innovative pay ment strategies that reward lon gitudinal care and create economic in centives for data-driven care delivery are needed, according to Joseph Alvarnas, MD, Director of Value-Based Analytics, and Associate Clinical Professor of He matology and Hematopoietic Cell Trans plantation, City of Hope, Duarte, CA. At ASH 2015, Dr Alvarnas discussed the episode-of-care payment model, em phasizing the importance of realigning infrastructure to support a continuum of care instead of restructuring healthcare based on the next intervention. “Hematologists need to ensure that their care delivery model is based upon achieving ‘systemness’ in care,” said Dr Alvarnas, “which means both seamless
© American Society of Hematology. All rights reserved.
Redesigning the Payment Model for Acute Leukemia: Benefits and Challenges of the Episode-of-Care Model “While the sensibilities behind the episode-of-care payment model are correct, it is unclear whether this particular financial model is suitable for acute leukemia.”
multidisciplinary care coordination and transparency and consistency of care processes. The entire system must be aligned around patients’ needs.” High Variability of Cost and Complications in Acute Leukemia
“While the sensibilities behind the episode-of-care payment model are cor rect,” he added, “it is unclear whether
—Joseph Alvarnas, MD
this particular financial model is suit able for acute leukemia.” Acute leukemia represents only 1.7% of all cancer diagnoses but accounts for nearly 5% of all cancer spending, total ing $5.4 billion annually, said Dr Alvar nas. At the same time, on a case-by-case basis, many studies have shown high interpatient variability in costs. “We’re not really sure how much it
costs to treat acute leukemia effectively, due to low disease incidence,” said Dr Alvarnas, noting that cost estimates fluc tuate from an average of $41,594 to $77,769 for patients who receive chemo therapy to $128,630 for patients whose disease relapses. “Predictions of costs are unlikely to achieve statistical significance without wide margins,” he observed. In addition, the treatment of acute leukemia is rapidly evolving as a result of a growing understanding of cytoge netic, molecular, and genomic risk fac tors. “There are many patients for whom there is no clear standard of care,” said Dr Alvarnas. Furthermore, escalating pharmaceu tical costs, particularly targeted agents, and a high variability of complications that cannot be prevented, make build Continued on page 11
10
FEBRUARY 2016
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
