Experts Share Concepts of Quality Measures and Pay-for-Performance at the Annual ASH Meeting

Quality measurement, public performance reporting, and pay-for-performance have rapidly translated into established processes in the delivery, assessment, and evaluation of medical care in the United States, accelerated by the Affordable Care Act and CMS’ proposed transition to value-based reimbursement. On the first day of the annual meeting and exposition of the American Society of Hematology, held December 5-8, 2015, in Orlando, Florida, experts discussed these measures and what they’d mean for a practicing hematologist in the coming years.

Some of the questions that were explored in this session included:

• Are current quality programs heading in the right direction?
• Can quality measures really help physicians improve patient care?
• Are quality measures ever more harmful than helpful? Does pay-for-performance work?

Helen Burstin, MD, MPH, from The National Quality Forum (NQF), during her talk, Quality Measures, Quality Reporting, and Value-Based Remuneration: How Did We Get Here and Where Are We Going?, said, “As we move toward the new world of value-based payments, we really need to understand how did we get here and where are we going with these measures?”

The federal government, Burstin explained, came up with a National Quality Strategy, the premise for which is better care, healthier people and communities, and smarter spending. These were national priorities that were laid out.

“The push to population health in communities is a big area that needs prioritizing. The move from volume to value is a sea change, and there’s significant growth expected in the move from fee-for-service (FFS) linked to quality payments and alternative payment models. By 2018, we expect 50% adoption of alternate payment models and 90% FFS-quality link is expected,” said Burstin.

The question remains, though, whether we have the tools to bring about this change and whether we are ready for this move.

There are of course challenges to be surmounted, including tensions in measurement, according to Burstin, which include:

• While outcomes measures are included to deduce accountability, process measures are primarily used for quality improvement.
• The measurement burden for providers and clinicians creates the need for developing more comprehensive measures.
• While the need is primarily for system-level measurements, individual clinician-level measurements are being set by the Medicare Access & CHIP Reauthorization Act of 2015.
• Limited set of core measures (need metrics to meet needs of each specialty)

As we plan to move away from process-based to outcomes-based measures, there’s a need to think of modifying processes that can improve outcomes. A major move in the healthcare field, Burstin said, is the incorporation of patient-reported outcomes (PROs) into quality measures. “But these measures are riddled with challenges—they are not widely used in practice, more-so in clinical trials,” and we don’t have a method yet to aggregate PROs, she added.

Burstin listed the following challenges commonly faced when utilizing these measurements:

• Persistent measurement gaps
• Potential for unintended consequences
• Alignment and harmonization of measures
• Complex measurement science issues

Outcomes measure themselves have their limitations, said Burstin, including, but not limited to:

• Patient selection can lead to differences across physician or hospital population (risk adjustment)
• Small sample size or event rate
• Longer term outcomes may be difficult to track
• Ideal outcomes may not be achievable

Risk adjustment, she believes, is a significant challenge to surmount due to factors that are difficult to control for, including genetic characteristics, demographic characteristics, clinical factors, health-related behaviors, and psychosocial behaviors.

Burstin said that NQF is working with health plans and CMS in an attempt to standardize and avoid “me too” measures. “This would help overcome variation and align the innumerable measures currently used in practice,” she explained. There are separate measures at the federal-programs level, health-plans level, and state-programs level, in addition to individual provider-generated measures and ratings. All of these separate measures need to be evaluated and aligned to avoid overlap and unnecessary burden, she said.

“The purpose of measurement is to improve healthcare quality, and we need to understand that they are the means to an end,” said Burstin.

She ended with the following quote from Albert Einstein: “Not everything that can be counted counts and not everything that counts can be counted.”

According to Andrew Ryan, PhD, MA, from the department of Health Management and Policy at the University of Michigan, currently, the primary platform for measuring quality is the Physician Quality Reporting System (PQRS). “A majority of the 280 measures are related to clinical process performance. These measures are in use for hematology.” He informed the audience that PQRS is now moving toward penalizing physicians for not reporting to PQRS.

Several studies have provided evidence of cost reduction, Ryan said, such as the hospital readmission reduction program, which has shown a significant decrease in readmissions. “However, public reporting has not improved outcomes or impacted consumer choice,” which has been a trend observed across the board with several models, Ryan explained.

One reason for this, he pointed out, might have been the inclusion of both inpatient and outpatient data by hospitals, rather than inpatient data alone, Ryan said, adding, “The validity of many performance metrics are questionable, along with disparities in payments from hospital incentive programs.”

He concluded his talk with several futuristic questions:

• Are PQRS measures taking us where we want to go?
• What is the role of hematologists in the larger system of accountable care?
• How should drug pricing and costs be accommodated in value-based payment systems?
• What is the model for an ideal accountability system for individual hematology practices and individual clinicians?

These are just a few of the open-ended questions that we can hope will be answered over the next few years as we see increasing adoption of these measures and models in clinical practice.