The Affordable Care Act included provisions to accelerate the transition to value-based payment, including Accountable Care Organizations (ACOs). Many private sector insurers, providers and employers also are moving in this direction.
However, many of today’s measures are inadequate to the task of assessing and paying for value. Current measures focus on process and clinical outcomes, as opposed to health status, and few are based on patient-reported data that would measure the overall care experience.
In addition, most measures are add-ons to current work rather than an integral part of the care process, requiring manual chart reviews and retrospective data analysis. Not only does this make implementation burdensome, it limits opportunity for real-time feedback and adjustment.
These inadequacies create opportunities to implement new measures that will be more meaningful to consumers, clinicians, purchasers and policy makers. But to avoid a proliferation of measures that are inconsistent or questionable in terms of assessing value, a framework is needed to define specific measures for each component of value – health outcomes, patient experience and per capita cost (see Table 1, click to enlarge).
For each component, the framework assumes two types of measures will be required:
- Overall measures for public reporting and payment that depict changes in health status and costs over time.
- Sub-measures to evaluate practitioner performance, improve care, and determine whether value measures are having the appropriate effect.
Overall measures will be more useful to purchasers, consumers and other stakeholders, while health systems will need the sub-domain measures for continuous quality improvement purposes.
Recommended measures of health outcomes are shown in the first column of Table 1. Overall measures include those that apply to virtually all adults, including global measures of functional status that cover physical and mental health (i.e., PROMIS-10) and risk status (i.e., Institute of Health Metrics and Evaluation’s modifiable risk index).
These are divided into sub-domain measures for healthcare systems’ use, including physical, mental and symptom measures, as well as biometric and behavioral predictors of mortality.
Based on input from consumers, the framework envisions measures that can assess the total experience (second column of Table 1).
Sub-domain measures include patient activation, access to care, communication with providers, shared decision making, coordination of care and care transitions. These measures were selected because they are critical determinants of the care experience, contribute to health outcomes, and reflect patient engagement.
Although existing tools collect patient experience data, consumer advocates provided recommendations for how ACOs could best use patient-reported data, including:
- Developing a common infrastructure to collect experience data across settings;
- Collecting qualitative and quantitative information that is used routinely for improvement;
- Using a diverse array of collection methods, including Internet/email, interactive voice response, text, mail, social media, patient portals, advisory councils, comment cards, focus groups, etc.;
- Annual data collection for payment and public reporting, but more frequent assessments for quality improvement and care redesign;
- Measurement at the both the provider and ACO level; and
- System and medical leadership, education and support to ensure that patient experience data is collected and used to improve care.
Costs Per Capita
To measure accountability in a way that is useful to those receiving and paying for care, the framework envisions reporting costs as a total per capita (3rd column of Table 1). Traditionally limited to payor expenditures, the framework captures goes beyond this to capture non-healthcare expenses as well, such as lost productivity or wages.
In addition to expenditures and utilization, the framework envisions measures that reflect potential “overuse” of services, including ER visits, imaging, laboratory diagnostics, end of life care, non-emergent/elective percutaneous coronary interventions (PCIs), C-sections and unplanned readmissions.
Successful Implementation Of The Framework
Federal policy is needed to develop and test measures to determine if they are valued and understood by consumers, as well as their ability to assess functional health, risk, patient experience and total costs. Grants through the Agency for Healthcare Research and Quality, CMS or other federal agencies will be needed to support measure development and testing. Some measures could be tested by the CMS Innovation Center through demonstration projects or the Pioneer program.
Once measures are proven, they can be expanded into the Medicare Shared Savings Program, value-based purchasing and programs being implemented for other segments of the delivery system. In doing so, CMS can be assured that measures in all pay-for- performance programs work toward a consistent goal, across the care continuum.
To ensure consistency, it will be important for the private sector to leverage the framework in individual contracts.
A common measures framework will support data-driven assessments of which systems truly deliver the most value, patient-valued outcomes and experiences, and the most cost-effective care. The old model of defining metrics because “the data is available” must give way to a more long-term and patient-centered approach in order to transform healthcare delivery and payment.