Top Takeaways from ASH: Quality metrics front-and-center in move toward value-based systems

During a special symposium dedicated to quality at the ASH Annual Meeting and Exposition, speakers addressed the role of metrics in health care, from their origins to importance.

The discussions focused on pay-for-performance, particularly how the strategy being used in the United States and elsewhere directly impacts physician and institutional remuneration.

“Pay-for-performance and quality metrics are no longer of theoretical importance to clinicians – they are real-time,” Lisa K. Hicks, MD, MSc, FRCPC, of St. Michael's Hospital, Division of Hematology/Oncology, member of the ASH Committee on Quality and session co-chair, told Healio.com.

Brian Bolwell, MD, chairman of the Taussig Cancer Institute at Cleveland Clinic, concurred.

Brian Bolwell

“The whole movement towards the value-based healthcare system is real, and we’re on that journey,” he told Healio.com.

Defining measures

Although value has generally, and reasonably, been defined as quality over cost, Bolwell said important debate around the definition of quality surfaced during the symposium.

“Much of quality in medicine has historically been process metrics, which is basically what is done,” he said, offering an example of clinicians not using routine PET scans for surveillance on patients with known disease progression, due to both cost considerations and considerations of exposure to radiation to patients.

“Alternative ways to define quality are patient-reported outcomes, or PROs,” Bolwell added. “This was increasingly talked about and I think will become increasingly important and increasingly popular.”

He noted there are also multiple ways to define cost, highlighting the continually-rising cost of drugs as a challenge in the fields of hematology and oncology.

The chief scientific officer of the non-profit National Quality Forum, Helen Burstin, MD, MPH, FACP, provided “excellent background” introducing the concept of quality metrics and displaying how they fit into health care, according to Hicks.

Lisa K. Hicks

This could include developing new cost analysis programs for treatment provided and understanding how performance measures set forth by insurers, institutions and certification agencies impact remuneration.

“Quality metrics are essential if we’re going to try and improve the quality of care that our patients receive,” she said. “If we’re not measuring, we won’t know whether we’re achieving the quality we want to achieve, and we won’t know whether any changes we make are working.”

With the lack of quality metrics relevant to hematologists and hematology patients illuminated in the session, Hicks noted it is time for academics and those with interests in quality to consider ways to enrich that pool.

Although acknowledging the utility of metrics may not create much debate, Hicks said the existing evidence for pay-for-performance specifically — reviewed in the session by Andrew Ryan, PhD, associate professor, Health Management and Policy, University of Michigan, Ann Arbor — is more controversial.

“The evidence is mixed,” Hicks said. Some studies suggest that pay-for-performance strategies improve performance in care, whereas others are less clear, she explained.

Nonetheless, Hicks underscored the bottom line drawing attention to the value-based system.

“Finances do seem to drive health care decisions,” she said, “and that is why this whole concept of pay-for-performance is attractive to policy makers.”

Changes underway

Another central piece of the equation in the quest for quality came to the forefront during a presentation by Lemeneh Tefera, MD, MSc, of the Center for Clinical Standards & Quality at the Centers for Medicare and Medicaid Services.

The talk focused on changes currently underway at CMS and the impact for clinicians who care for patients involved in the private-public partnership.

Bolwell highlighted two programs — the Merit Based Incentive Payment Systems (MIPS) and Alternative Payment Models (APM) — following the Medicare Access and CHIP Reauthorization Act passed by Congress in 2015.

“The MIPS program is going to be rather physician-specific and focused on quality resource use, clinical practice improvement and meaningful use of electronic health records,” Bolwell explained.

The areas of focus, he said, include: access, based on metrics such as same-day appointments for urgent needs; practice management; care coordination and care pathways; beneficiary engagement in decision-making with patients and families; and lastly, a patient safety checklist, especially for surgical procedures.

“The APM program certainly is heading in the direction of bundling, which is where the providers accept risk and basically agree to a certain set payment for an episode of care.”

Bolwell said these episodes can really be defined in any way; he offered an example in oncology of a provider or hospital receiving a negotiated fee to treat every patient for 100 days following diagnosis of a certain cancer.

“As opposed to being paid for everything that’s done, you’re paid a flat fee,” he said. “Bundled payments are an increasingly attractive way to try to control cost. From a provider perspective, the key to being able to manage bundled payments is to have an idea of what you do and what that costs.”

With many new immunologic and genomic targeted therapies now available in hematology, Bolwell conceded the high cost of pharmaceuticals does raises issues but said they can be handled.

“The way to manage this is to use care pathways or treatment pathways,” he said. “By updating them several times a year, you can incorporate cutting edge science and research, and yet do it in a rational way.”

Practice integration

With the mandate given to CMS by the re-authorization act but the language in it yet to be written, Bolwell encouraged clinicians to engage and take action.

“There will be an opportunity for comments, an opportunity for health care professionals to take the time to read what’s being proposed and to respond — because the comments are read,” he said.

Hicks agreed, saying “it’s really important for clinicians to educate themselves about the changes that coming through CMS, or at least to make sure there’s a point person in their institution or their practice group that is aware of the changes that are coming.”

Hicks conceded that change is always bound to be challenging, but she underscored that keeping an eye on the “big picture” of optimizing care for patients will be a united goal and serve as a grounding force during the transition.

For clinicians to move into the new paradigm with greater understanding and ease, Bolwell recommended providers utilize national organizations including ASH, ASCO and AMA as well linking up with major academic health centers that “have a pulse on” the changes.

“These organizations are there for a reason, to support their physicians, and this is all very high on all professional medical societies’ radar screens,” he said. “At the Cleveland Clinic, we build our own treatment pathways, and we’re happy to work with people from all over the United States to share them.” - by Allegra Tiver

Reference: Exploring the Promise and the Pitfalls of Quality Measures and Pay-for-Performance. Presented at: ASH Annual Meeting and Exposition; Dec. 5-8, 2015; Orlando, Fla.

Disclosures: Bolwell, Burstin, Hicks, Ryan and Tefera report no relevant financial disclosures.