Quality Measurement in the Value-Based Health Care Environment Presentation to PhRMA Lunch and Learn June 22, 2017 Tom Valuck, MD, JD Partner, Discern Health

Quality Measurement in Context Clinician Payer Patient Value 4. Health Data Impact 1. Health Data Generated Improved Quality, Lower Costs Incentives Health IT 2. Health Data Transmitted 3. Health Data Applied Measures

Quality Measure Lifecycle Set Measurement Priorities Identify and Fill Measure Gaps Develop and Test Measures Standardize and Harmonize Measures Select and Align Measures Implement Measures Assess Impact of Measures

MACRA Quality Payment Program (QPP) MIPS Performance Categories Measure Types Menu of 271 condition/specialty-specific and cross-cutting measures Reported using EHRs, registries, web portal Quality Alternative Payment Models (APMs) Advancing Care Information Requirements for demonstrating EHR use Based on former Meaningful Use objectives The APM definition requires that base payment rates for APM participants be modified by quality measure performance Improvement Activities Menu of 92 activities for implementation at the practice/group level Total per-capita costs Medicare spending per beneficiary Episode-based costs Cost

Data Sources and Types for Measurement Data Types Easier Access to Data Less Effective Measurement Claims More Difficult Access to Data More Effective Measurement Patient Surveys EHR Data Chart Abstraction Registries Clinical Data Care Provided Patient Safety Pharmacy Data Prescriptions Adherence Utilization Data Administrative/Billing Hospital Utilization Patient Data Functional Status Patient-Submitted Data

Measurement Data Source Issues Lack of Alignment and Standardization of Measurement Multiple programs use measures with slightly different specifications and attribution methodologies to measure the same thing Lack of alignment/standards can cause confusion, mixed quality signals Data Interoperability Need for health IT to be able to interact, share patient information, and acquire the complete picture of patient care Security issues and diversity among vendors are barriers Improvement of interoperability is a major ONC, CMS focus Reporting Burden Many measures, even EHR-based measures, often require manual data abstraction for reporting or quality assurance Need innovation to achieve accurate, efficient, real-time reporting

Patient-Reported Outcome Measures Patient Experience Surveys Example: CAHPS surveys for hospitals, clinicians, health plans Patient-Reported Outcome Measure:   “An instrument, scale, or single-item measure that gathers information directly from patients about how they are feeling, their symptoms, and any effects of prescribed treatment.” Functional Status Example: Reported functioning before/after treatment  References CMS Measure Development Plan Quality of Life Example: Survey questions about issues beyond health status -CMS Measure Development Plan

PRO Performance Measurement Issues PRO Data Collection Surveys, tools, apps, devices Data requirements: valid, reliable, secure, sustainable Patient-Reported Outcome-Performance Measure PRO-PM Specification Patient Response To hold a provider accountable for a PRO, patient-reported data must be converted into a performance measure (e.g., change in function over time) Potential for patient bias and variation due to: Cognitive/functional status Survey fatigue

Care Processes and Outcomes Patient-Reported Outcomes Monitoring and Evaluation for Unintended Consequences of Value-Based Payment VBP programs may create unintended consequences: Incentives to reduce costs without counterbalancing quality measures Focus on measured processes at the expense of care in other areas Pressure to reduce services for high-need/high-cost patients Programs Should Include Measures to Monitor for Unintended Consequences Care Processes and Outcomes Patient-Reported Outcomes Utilization and Cost Appropriate Utilization for At-Risk Care Shared Decision-Making Pre/Post Functional Status Patient Experience Surveys Provider Experience Surveys Cost of Care/ Population Savings Product-Specific Utilization

Measures for Risk-Based Contracting Agreement between a manufacturer and payer or provider under which the performance of a product is tracked in a defined population over time Payment is based on the achievement of health and/or cost outcomes Option 1 Option II Change in Outcomes End of Year Reconciliation Reward Payment Rebate Price Increase Price Decrease Prospective Price Change Worse Outcomes OR Improved Outcomes

Examples of Risk-Based Contracts Payer Pharmaceutical Company/Drug Outcome at Risk Cigna, Aetna, Humana Novartis- Entresto Hospitalizations for Heart Failure patients Aetna Merck- Januvia, Janumet Targets for Type 2 Diabetes Patients Harvard Pilgrim Amgen- Enbrel 6 Effectiveness Criteria (Including Adherence, Dose Escalation) Amgen- Repatha Patient Cholesterol (LDL) Targets

Key Takeaways Measurement is increasingly important as all settings of care transition to value-based payment and incentives grow Stakeholders throughout the health care system need to be aware of what measures are being used for what purposes, and the implications Measurement is changing as higher priority measures than traditional condition-specific process measures, such as patient-reported outcomes, are developed and the electronic data infrastructure is built New and better measures will enable new uses, such as risk-based contracting

Thank You tvaluck@discernhealth.com