It was fascinating to watch a video discussion online at the American Journal of Managed Care that was held this spring, focusing on outcomes measurement and patient-centered care in oncology. The April 22 video discussion involved a mixed group of managed care medical directors and medical group leaders.
Bruce Feinberg, D.O., vice president and chief medical officer at the Dublin, Oh.based Cardinal Health Specialty Solutions, the panel’s moderator, began by asking the other panelists how they believed peer review of oncologists would change over time, as oncologists and other physicians come to be measured on the quality of their advisement of patients around their care options and health status, among other elements.
Michael Kolodziej, M.D., national medical director for oncology strategy at the Hartford-based Aetna, Inc., noted that “There’s actually excellent evidence that a physician assessment of patient performance status is a very poor surrogate for actually how well a patient is performing.” He went on to say that “The kinds of questions [we ask] and how we collect the information and operationalize it into shared decisionmaking, for example, does not exist yet, but that doesn’t mean it won’t.” He gave the example of the patient who goes in to discuss the decision as to whether to take the PSA test for prostate cancer, with his physician. “At some point in the not-so-far future, how you grade that interaction with your physician will be collected,” he asserted, “and input regarding how people like you process that information, what they find useful in that discussion, will be presented to the physician so that they can enhance that total morass of PSA testing. But the tools don’t exist yet, and they’re not integrated into the workflow yet.”
Feinberg asked Brian Kiss, M.D., vice president of healthcare transformation at BlueCross BlueShield of Florida how such developments might impact how health plans will reimburse physicians in the future. “You know,” Kiss said, “I think if we have good tools and we have something that’s objective” in terms of performance measures, “we can begin to incorporate it into payment plans. I mean, this is a form of medical quality; fundamentally, what we’re talking about here is satisfaction in physician interaction with the patient, and we’ve not been good at measuring” how such physician-patient interactions correlate to outcomes. “So one of the problems we have when we try to assess care and assign payment to high-quality care in all the domains of quality, including technical quality, interpersonal quality, and efficiency of delivery, is, we need good measurement tools. Once we’ve developed those systems that have reliable, reproducible, valid tools,” tools that are culturally and linguistically “relevant,” he added, then health plans will begin to disparately reward physicians based on their care delivery quality.
Ted Okon, executive director at the Washington, D.C.-based Community Oncology Alliance referred to a pioneering program being sponsored by the CenterS for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMI), called the Community Oncology Medical Home, or COME HOME, grant program. Under that program, launched in 2012, seven oncology practices in six states have been developing innovative approaches to try to overcome fragmentation of care, suboptimal patient outcomes, high costs, and patient dissatisfaction, in the cancer care arena.
As Okon noted, within the practices participating in the Come Home program, “You’re seeing some pretty radical fundamental changes. Very specifically,” he said, “instead of having a dedicated nurse navigator, that function of nurse navigation is built through the practice.” Further, he noted, “There are actually 19 measures of quality and value that are actually being incorporated into the EMR systems of the practices.” And he elaborated on the common situation in which a cancer patient experiences a medical crisis during evening or weekend hours, and typically ends up in the emergency room or as a hospital inpatient because of the inability to access a physician or care manager who can make immediate care management decisions. Instead, he noted, “In those practices, there’s basically 24/7 access to someone in that practice who has the chart, knows what to do, and can talk to the patient. What’s fascinating about this,” he said, “is that we’re actually seeing a sea change being implemented right now, not just a bunch of hype, not just what may come down, but what’s happening really right now.”
Indeed, in March, Okon had given at a cancer care management conference a presentation on some of the results of the COME HOME initiative, citing, among other things, improved adherence to clinical pathways, lower ED utilization and lowered hospitalization rates, better balancing of drug and services reimbursement, advancement in applying population health concepts to cancer care, and improved collaboration between payers and providers, as early results of the COME HOME initiative.
I have to say that I found the AJMC panel discussion fascinating along a number of dimensions. First of course, the fact that the oncology practices involved in that initiative are really seeing results, is tremendously heartening. Beyond that, though, it is very clear that healthcare payers are ready to begin to revamp value-based reimbursement systems to reward the physicians and physician groups who can demonstrate more effective advisement and care management of patients leading to improved clinical outcomes and enhanced health status.
Of course, once one gets into the trenches of this kind of outcomes measurement, things get very complicated very fast. That said, CMIOs and other clinical informaticists are soon going to be knee-deep in collecting, analyzing, sharing, and publishing these kinds of data points, as U.S. healthcare providers are required to become ever more transparent and accountable. And why not? After all, virtually every other industry that touches consumers, and many that don’t, is being forced these days to become more transparent and accountable.
In fact, some of this discussion makes me think of consumer-focused services like Yelp! and others, and sites like Hotels.com that help consumers find hotels. As most everyone knows, the restaurant with dreadful food, poor service, and bad restroom hygiene will quickly get slammed online via services like Yelp! and the hotel with dirty rooms and slovenly front desk staff will receive damning reviews on Hotels.com. Conversely, the hotel with beautiful rooms and great service will receive plaudits, and potentially much more business.
Is healthcare much more complex than the hotel and restaurant industries? Yes, absolutely. And of course, the delivery of specialty care, as in oncology, is even more so.
Yet the reality is that, in a healthcare industry whose purchasers and payers are determined to force providers to provide and document better value for reimbursement, the push in that direction is inevitable, particularly as healthcare consumers are increasingly being forced into high-deductible health plans, in the context of ever-increasing overall U.S. healthcare costs.
So the march towards far deeper levels of patient and payer assessment of physician, hospital, and other provider care delivery quality—including not only around clinical outcomes, but also around service and advisement quality—is unavoidable. And healthcare IT leaders, most particularly clinical informaticists, will be key players in the dynamic going forward—whether or not physician groups get rated with the equivalent of forks or spoons or any other little icons as in those other consumer-facing industries. And the physician groups, hospitals, and other patient care organizations willing to begin the deep process work to achieve better results along all dimensions, with strong IT and analytics facilitation, will inevitably reap the early rewards.