Transcript: Using Patient-Reported Measures and Value-Based Payment Models to Promote Patient-Centered Cancer Care

Theresa Schmidt:  Hi, everybody. Welcome to the Journal of Clinical Pathways. I'm Theresa Schmidt from Discern Health. I'm joined today by Kimberly Westrich from the National Pharmaceutical Council.

Today, we're here to talk about an article that we recently published in JCP, but we're also here to talk about patient-centered care. We've been talking, as an industry, about patient-centered care since the 1950s.

I Googled this, actually, in preparation for today's presentation, and it's actually become more of a buzzword since the 2000s, but somehow, with all of this history, our industry still struggles to keep patients at the center of what we do.

Today, we'll be talking about how using patient-reported measures and value-based payment programs can help promote patient-centered care, specifically in the field of oncology. Before we get started, maybe we should introduce ourselves. What do you think?

Kimberly Westrich:  I think that makes sense.

Theresa:  As I said, I'm Theresa Schmidt. I'm a vice president at Discern Health. We're a strategic advisory services and research firm. We're part of Real Chemistry.

We do a lot of work in defining and measuring value in healthcare, thinking about multiple perspectives from payers to patients, of course, to providers, and how to create incentive systems that help people do the right things and have the right outcomes.

Kimberly, do you want to introduce yourself?

Kimberly:  Sure. Thanks, Theresa. I'm Kimberly Westrich, vice president of health services research for the National Pharmaceutical Council. For anybody who's not familiar with NPC, we're a health policy research organization, and we focus on the role and value of innovative medicines to improve patients' lives.

Theresa mentioned the article that we collaborated on recently. It was published in the April issue of the Journal of Clinical Pathways, and it's entitled "Patient Voices in Value-Based Cancer Care: Priorities for the Biden Administration." It basically includes some opportunities and some recommendations for ways that we can build on and move beyond prior value-based payment models to incorporate the patient voice to patient-reported measures.

I do want to make sure that we acknowledge our coauthors at the top of this webcast here. Our coauthors include Theresa's colleagues from Discern: Jacqlyn Riposo and Tom Valuck; as well as Ethan Basch from the UNC Lineberger Comprehensive Cancer Center; and Mark McClellan from the Duke-Margolis Center for Health Policy. We're grateful to them for their collaboration.

Theresa, how about if we start with you sharing a little bit about how our article aims to connect the dots between patient-centered care and payment for cancer care?

Theresa:  I'd be happy to. Stakeholders such as CMS, everybody knows CMS, National Quality Forum, and PCORI, the Patient-Centered Outcomes Research Institute, and a lot of stakeholders across healthcare have raised awareness of broad areas where patient input is supercritical to enhancing patient-centered care.

One of those areas is payment programs. They're super high on the list because they are powerful levers to make providers focus and payers focus on what matters to patients, and these levers hold providers accountable by incorporating patient-reported measures.

Now, I use that term deliberately, by the way. Many of us are used to the term patient-reported outcomes measures, but these are patient-reported measures of both outcomes and experiences, and they're being incorporated into payment models.

Our article discusses this. Our article talks about the future of CMS oncology value-based payment models and the incorporation of these patient-reported measures.

This project has a pretty long history started with NPC and Discern teaming up to conduct research to better understand the landscape of oncology patient-reported measures and patient-reported performance measures including those used in payment programs.

Through this research, we identified barriers to implementation. We recommended a number of different solutions for public and private payers to accelerate the appropriate use of patient-reported measures and payment programs including value-based payment programs.

Our article focuses on our recommendations specifically for the next CMS or CMMI value-based payment program after the Oncology Care Model census. We don't know at this point whether that's going to be oncology care first or whether it's going to be something else entirely.

You may be wondering watching on at home, why NPC is so interested in value-based payment models and CMS specifically, Kimberly?

Kimberly:  That's a great question. Why do we care about CMS value-based payment models? Really quite simply, we want patients to have access to the medicines that they need, the ones that are most appropriate for them, and the highest value.

You alluded to this a bit in what you said before that CMS value-based payment, it can help make that happen because there are levers. It does reinforce those value-based incentives and helps keep everyone accountable and brings the patient voice in.

Theresa:  Why oncology, Kimberly, specifically?

Kimberly:  Why oncology? Oncology, it's a very important area. There's been a lot of innovative medicines in the oncology space over the past years that have enabled many patients to live longer fuller lives, but sometimes there are barriers to accessing the oncology space in particular that aren't always aligned with value-based patient care.

One example of this is some clinical care pathways, where they're relying on cost-based criteria rather than clinical criteria and what makes the most sense for patients. We think that patient-centered value should be the main driver of access and that patient-reported measures are one important way to keep the patient voice front and center. That's why oncology.

Theresa, you also mentioned a bit about some of the work that we've done in the past. We've partnered on a few projects now that are related to oncology, but also looking at accountability more broadly, how do you see the intersection of patient-reported outcomes measures intersecting with the larger landscape?

Theresa:  That's a great question. Our core recommendations from our oncology research really go beyond that field because they include things like involving patients and caregivers during development in patient. That's not something you should restrict to the field of oncology.

Selecting or developing measures to fill gaps, such as measuring shared decision-making, health-related quality of life, goal-concordant care—these are important topics to many patients across the United States and not just cancer patients. We also recommended reducing reporting burden through the use of validated standardized measures.

There have been many conversations at CMS about reducing provider-reporting burden and also reducing patient-reporting burden because remember, patient-reported measures are the surveys like the CAHPS survey that patients are asked to complete sometimes multiple surveys after a given clinical encounter.

That can add up for patients, and it can certainly add up for providers who are administering these surveys and processing the results. Reducing burden through validated and standardized measures is one of those recommendations that is goes way beyond oncology, as well.

Also, providing support for implementing these programs, that goes hand-in-hand with reducing provider burden. Just reducing the number of measures doesn't help providers with implementation of the systems they need to collect the data for these measures.

I would also say that there are indications in the policy landscape that the timing is right to implement some of these recommendations. The Biden administration has hired and appointed a number of folks that have maintained their commitment to value-based care and the likelihood of health equity, which is another incredibly important concept, being a focus.

CMS administrator, Chiquita Brooks-LaSure, and CMMI director, Liz Fowler, we all know, were key players in the implementation of the Affordable Care Act, which brought value-based care to the forefront of many conversations nationally.

Fowler, for example, has made comments that the COVID pandemic reinforced the need for value-based care. She noted that CMMI is currently looking at all of their existing value-based payment models to, as she said, define both the vision and framework for CMMI as a whole.

I attended a couple of weeks ago the National Quality Forum's Annual Meeting online. Lee Fleisher, who is the current CMO and he is also the director of the Center for Clinical Standards and Quality at CMS, said that CMS intends to continue to leverage quality measures to drive value-based payment models, and CMS is committed to a person-centered approach and quality measures and in value-based incentive programs, which ensure that measures address safety, address health equity, address all of these concepts.

As they're continuing to move to value-based landscape forward, it's critical to keep recommendations like ours in mind for incorporating patient-reported measures in these new and evolving programs.

Kimberly:  Theresa, those are some great observations. I'm encouraged by the appointments. I'm encouraged by the comments that you just shared. I think the implications are positive for future value-based care models, including those outside of oncology.

It's heartwarming. It's great to hear the commitment to these models which are aligning the incentives to drive accountability in the health system and bring value forward for the patient.

Patient-reported outcomes do continue to be a hot topic. The American College of Physicians recently released some recommendations that put a caution out there against the use of patient-reported outcome-based performance measures in accountability programs.

You mentioned validation earlier. One of the things that showed up in these recommendations are highlighting some of the challenges in developing and applying these measures, cautioning that data are needed to demonstrate that these measures can actually improve care, that they can be effectively used to compare positions.

Based on our work together, what do you think about this recommendation and the cautions that are inherent in it?

Theresa:  They're important cautions, but we do know that determining the association between whether care is actually improved and improvements in the patient-reported outcomes at the provider level can be tricky. Accountability and attribution is always a tricky concept in quality measurement. Providers, they tend to push back on measures that they're not in control of.

In the world of population health, where we're moving towards entities taking accountability, taking on risk for populations, even though no one entity can completely control health outcomes, especially in a world where social determinants of health plays such a big part, if we don't hold anybody accountable, then no one is incentivized to work towards improving these outcomes.

I would say that even though accountability itself is the question, it shouldn't be the block to having measures that are important to patients included in reimbursement programs. That would be my instinct. What about you, Kimberly?

Kimberly:  That makes sense. To ACP's point, we absolutely do need to make sure that they work as intended. I think that patient-reported measures should go through the same rigorous testing that any other measures that are included and accountability programs go through.

We need to make sure that there's evidence that the measures are meaningful to the patient, that they can effectively distinguish between organizations, and that they're correlated with the outcomes that are important to patients.

Theresa:  I couldn't agree more. You may have also seen recently the 2022 Physician Fee Schedule was released. It made a little splash, it always does.

CMS has been talking for a year or for a couple of years about adding MIPS value pathways to the quality care program to help streamline requirements for reporting, reduce physician burden, and improve quality performance, as it moves them closer into value-based payment models with shared accountability.

Previously, CMS had announced that MVPs should include the patient voice whenever possible. This rule included the first seven MVPs. We're getting our first peek at what these MVPs are going to look at. How do they align with the research you and I have done in some of the recommendations that we've made?

Kimberly:  Great question. None of the MVPs focus on oncology, so we don't have that direct connection to our article and our recommendation, but I think that we do see a few of our principles popping up in the MVP. It's a little nuanced, so stick with me here as I walk you through the ways where we do see them.

I'd say that we've got three of our principles showing up in the MVP. The first one is, like you said, the incorporation of the patient voice in the measures. The second one is a reflection of patients being included in the care decisions through shared decision-making. The third one is what we call goal-concordant care.

Let me go back and give you some of the specifics. First, the incorporation of the patient voice to the patient-reported measures. We do see this incorporation of the patient voice in five of the seven MIPS value pathways.

They do include either a patient-reported process measure, say, functional status, or at least a process measure for collecting that patient-reported measures, say, functional status assessment. That's seeing the incorporation of patient voice in patient-reported measures.

The second principle is including patients in their care decisions, and shared decision-making is one way to do that. Where do we see that?

As a priority concept, shared decision-making is included as one of ten summary measures in the CAHPS for MIPS clinician and group survey. You mentioned CAHPS earlier. That's a measure that shows up in the emergency medicine MIPS value pathways, and it also shows up elsewhere in MIPS.

Our third priority concept, goal-concordant care. This is somewhat hidden in the chronic disease management MIPS value pathway. It's reflected in one of 11 items in the person-centered primary care measure. This is a patient-reported outcome performance measure and the exact language for this is, "over time, my practice helps me to meet my goals."

We do see some of our principles. We see evidence that CMS is working towards these important concepts, but of course, the MVPs are not going to be implemented until 2023. It's going to be a little bit of time until we can see whether this movement towards the MIPS value pathways can change behavior in the areas that we're watching.

Theresa:  It sounds like an opportunities for further research. Don't you think?

Kimberly:  Definitely.

Theresa:  Kimberly, it's always great talking with you. Thank you for taking the time to work on this article with us and for joining me on this webcast today, of course, for all NPC's support for this fabulous research.

To our listeners, thank you for joining us on this webcast as well. Definitely check out the article, and feel free to reach out to either one of us with any questions. Finally, thank you to the Journal of Clinical Pathways for the opportunity to have this discussion.

Of course, for the latest updates on issues related to the development, implementation, and evaluation of clinical pathways, please check out the JCP website at www.journalofclinicalpathways.com.

Kimberly: Thank you.