Exploring Quality Measures Under Value-Based Purchasing Models

June 22, 2017 - CHICAGO – Jason Goldwater, MPA, MA, Senior Director of the National Quality Forum, recently likened the value-based purchasing transition to the evolution of music at Xtelligent Media’s Value-Based Care Summit in Chicago.

Music started with the radio. Individuals could listen to whatever came out of the device. Fast forward to the age of the iPod and individuals can now store up to 100,000 high-quality songs in the palm of their hand.

In a similar fashion, value-based purchasing has put massive amounts of healthcare data into the hands of providers, patients, and payers. However, the increased access to healthcare data has presented several challenges for quality measure development.

“There are a number of challenges: being able to directly attribute physicians to the care that they are providing,” he told attendees. “Back in the day, we were trying to wrap our heads around how to actually measure outcomes and measure processes. Nobody could figure out how to do it, at least in the beginning.”

“Here we are in 2017 and we have roughly 2,700 quality measures,” he continued. “The thing is, out of the 2,700 quality measures, there is a lot of variation. Some of these measures are very similar and there is a slight variation. What measure is the best one that represents the best value to the patient? That is still a challenge and has been articulated.”

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Another challenge providers are facing with the value-based purchasing transition is the limitation of existing health IT.

“We are still not fully interoperable yet and there is still some dissatisfaction with the use of EHRs amongst physicians,” he stated. “There are still issues with electronic quality measures.”

To overcome value-based purchasing challenges, Goldwater pointed out that alternative payment models should focus on outcomes and address the challenges presented with the industry-wide transition to quality-based healthcare. On a basic level, outcomes need to evaluate patient outcomes and healthcare costs in order to assess care delivery effectiveness.

Digging deeper, clinical outcomes allow healthcare organizations to identify care variations. A major component of value-based purchasing models is to establish care delivery protocols. Providers follow the care pathways and protocols to deliver the highest quality and most cost-effective care to patients.

Clinical outcomes allow healthcare organizations to identify care variations and if protocols are not being followed.

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As a result, clinical outcomes should help healthcare organizations to reduce spending over time since the care pathways deliver the most efficient care.

“Patient experience has become almost central to quality measurement.”

Additionally, focusing on clinical outcomes under value-based purchasing models allows healthcare organizations to understand and analyze the patient experience.

“It has grown in a way that patient-reported outcomes have more important than they ever have before,” he explained. “In the past, it was really to look at clinical outcomes, processes, and structure of care.”

“Patient experience has become almost central to quality measurement,” he continued. “As we transition into value-based care, it helps to identify the appropriate focus.”

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Using patient-reported outcome measures, providers can pinpoint the most important healthcare discussions for each of their patients. This also allows providers to access timely data because they are addressing patient concerns in the moment rather than waiting for patients to come back into the office with additional issues.

Consequently, communication between providers and patients improves with the use of patient-reported outcomes.

However, healthcare organizations are not leveraging all data sources to access patient-reported outcome information, Goldwater argued.

“There is a fatal flaw with how we do patient-reported outcomes at the moment and that is you have to rely on an instrument to be able to provide that information,” he stated. “A patient has to fill out assessments. Those forms are not created by patients. Those forms are created by physicians. The physicians creating them are using their collective knowledge on what they think is important to the patient.”

“There’s another layer to this,” he added. “There is information that is available without having to go to these type of standardized instruments. We have technologies and mobile devices that can provide information to the provider. We have the ability to really get out what really concerns patients.”

For Goldwater, this additional source of patient-reported outcome data is social media.

“Social media was never thought of as a place where patients would discuss their healthcare concerns,” he mentioned. “There is absolutely a huge repository that can absolutely be used to determine what type of patient-reported outcomes are important and what patient-reported concerns we should be interested in.”

Goldwater shares his experiment with using Twitter to gather patient-reported outcome information. Some senior management staff at the National Quality Forum doubted that patients were talking about their healthcare concerns on Twitter. They thought it was unlikely that patients would be tweeting about chronic obstructive pulmonary disease (COPD).

However, Goldwater found several patient-reported healthcare concerns among 500 tweets in a 30-day period. For example, the tweets revealed that many individuals were confused about the differences between COPD and asthma.

People also expressed concerns and questions about the side effects of their COPD medications.

“So, I looked to see if there were any patient-reported outcomes that reflected these concerns,” he said. “None of them did. When we have data like that, we can use it to formulate what those measures should be and what sources of data we can use to populate those measures.”

The emphasis on patient-reported outcome measures, however, does not negate the importance of process measures. The measures may be easy to develop and comprehend, but they are key to realizing quality improvement.

“Their information is an easy way to determine if protocols are being followed,” Goldwater explained.

In addition, value-based purchasing models must promote integration of the environment, technology, and providers, Goldwater stated.

Geography also plays a key role in value-based purchasing programs. The model should expand beyond the reach of traditional boundaries.

This is where telehealth initiatives come in, he added. Using telehealth programs, healthcare organizations can achieve the expanded geographical reach individuals who may not have had access to healthcare services.

Finally, healthcare organization should implement interoperable health IT systems that can appropriately track patient outcomes and, importantly, healthcare costs.

“We have to have the ability to exchange information between members of care teams and between patients, but we have to have an infrastructure that supports collaborative health,” he said. “We have to have the infrastructure to support telehealth. We have to have a system that integrates this information and provides analysis in order to have physicians use their best judgment to determine the appropriate care path.”

With the four components of value-based purchasing (outcomes, integration, geography, and technology), healthcare organizations can effectively implement quality-based care. Although organizations need to select the most appropriate alternative payment model.

“There is no one value-based model that works for everybody.”

The global accountable care organization offers the greatest opportunity for care coordination and physician alignment, but organizations can implement a range of alternative payment models depending on their investment plans. Organizations can choose simpler models, such as pay-for-performance or quality-based reimbursement, to more advanced, risk-based arrangements, such as focused accountable care organizations and bundled payments.

To identify the appropriate value-based purchasing model, Goldwater advised healthcare organizations to make a value-based purchasing transition plan, understand that implementation is not easy, pay attention to market forces, and address the potential trade-offs of implementing a particular model.

“There is no one value-based model that works for everybody,” Goldwater said. “You really have to know the direction you are going in. The most appropriate model may not be the easiest to implement.”