1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Thank You