Proposed Framework for Patient-Centered Outcomes-Based Measures in Alternative Payment Models

ABSTRACT

Objectives: Alternative payment models (APMs) are part of a growing shift from volume-based, traditional fee-for-service payment models toward payment for value. To date, however, patients have been largely omitted from efforts to design new payment models. We sought to identify key characteristics of outcomes-based quality measures to inform future APMs that are more patient-centered.

Study Design: Using oncology as a learning case, we explored gaps in current APM quality measures, then engaged multiple stakeholders to identify and prioritize key characteristics of outcomes-based quality measures to guide future APM development.

Methods: We used a mixed-methods approach that consisted of (1) literature review, (2) key informant interviews, (3) stakeholder work group (involving group discussions and completion of an online prioritization survey), and (4) synthesis.

Results: Based on the lessons generated at each step of this exploratory project, we suggest a framework to guide deliberations among payers, providers, patients, and other APM stakeholders when selecting outcomes-based measures for future APMs or other value-based payment models.

Conclusions: The proposed framework offers a stepping stone on the path to clinically meaningful, patient-centered, high-value care. Next steps may include a broader review of gaps in APM quality measures across multiple therapeutic areas, additional vetting from a more diverse group of stakeholders, or a formal consensus.

Am J Manag Care. 2021;27(2):80-84. https://doi.org/10.37765/ajmc.2021.88586

Takeaway Points

Based on perceived trends toward more patient-centered value-based care and with multi­stakeholder input, we propose a framework to guide deliberations among payers, providers, patients, and other alternative payment model (APM) stakeholders when selecting outcomes-based measures for future APMs or other value-based payment models. Within the proposed framework, core outcome sets are considered key sources of patient perspectives on outcomes of importance. Although this framework has yet to be vetted by a broader stakeholder group, it has the potential to ensure the right outcomes-based measures of APM success by connecting patient values from research across the research-care continuum to the decision-making bodies that are responsible for shaping payment policies that ultimately influence the patient experience.

Alternative payment models (APMs) are part of a growing shift in health care away from traditional fee-for-service payment models toward payment for value. APMs use performance-based payments derived from quality measures to incentivize health care practitioners to make economical care decisions while maintaining or improving the quality of care. To date, patients have been largely omitted from efforts to design new payment models.¹ Current quality measures in APMs are primarily process-based, measuring success by the reporting and activity of a provider,² as opposed to outcomes-based, gauging how patients fare after receiving care.

Using the Oncology Care Model (OCM) as a learning case, we explored gaps in quality measures for APMs. An Advanced APM under the Center for Medicare & Medicaid Innovation, the OCM encourages clinicians in physician group practices to provide “higher-quality, better-coordinated oncology care at a lower cost” for patients undergoing chemotherapy^3,4; OCM practices have the potential for greater cost savings but share some financial risk related to patient outcomes and expenses. We then engaged stakeholders to identify key characteristics of outcomes-based quality measures in APMs and propose a framework to facilitate patient-centeredness in future APMs.

Approach

Our mixed methods approach consisted of (1) a select literature review, (2) key informant interviews, (3) a stakeholder work group, and (4) synthesis.

Literature search.We conducted a targeted review of current literature on trends and challenges in existing APMs. Between January and March 2018, we searched the peer-reviewed literature related to APMs, oncology quality measures, and the OCM. We also searched the gray literature, expanding to value-based payment models and public and private payer APMs.

Key informant interviews. The literature shaped questions for key informant interviews with experts who could provide a deeper understanding of issues around the OCM and oncology quality measures, more broadly. Semistructured interviews were conducted by phone during March and April 2018 and lasted 30 to 45 minutes each.

Multistakeholder work group. A multistakeholder group was recruited to provide overall project guidance, help interpret literature and interview findings with their professional insights, and share their own perspectives on key project questions. The work group convened remotely between May and July 2018, before and after they completed an online prioritization survey (Qualtrics) in which they ranked potential characteristics of outcomes-based quality measures in an APM context. To facilitate consistent understanding across the work group, members received a stakeholder briefing document summarizing select literature and key informant interview takeaways. Members were given the opportunity to discuss the material remotely prior to completing the online exercise and then again to discuss their reactions to and results from the online exercise prior to synthesis.

Synthesis. Combining the findings from literature, key informant interviews, and multistakeholder work group input, we synthesized the findings into a draft framework and shared it with the work group for written comment.

RESULTS

Literature

Noted missing perspectives in APMs include those of patients⁵ and clinicians.^6,7 Emphasizing utilization, cost, and short-term complications, existing APM quality measures can seem to sacrifice clinical relevance for feasibility.⁶ In certain specialties, there are even concerns that current quality and spending measures could create unintended disincentives that may negatively affect patients—for example, disincentivizing the proactive identification of patients likely to benefit from palliative care.⁸ In a broad quality measurement context, Baker and Chassin recommend that improvements in care lead to improvements in an outcome within a measurable period of time and that a strong process-outcome link should exist (eg, an action in a care process has a known effect on the outcome).⁷ Regarding oncology quality measure selection, Kline et al suggest that an outcome should be captured in a clearly defined episode in which cost savings can be achieved and within which change may reasonably be observed.³

At a high level, OCM quality domains (communication and care coordination; clinical quality of care; patient safety; and person- and caregiver-centered experience and outcomes) seem to suggest an intent of patient importance. However, there are still suggestions to include outcomes with greater relevance^3,9: patient-reported outcomes (PROs), cross-cutting clinical outcomes (outcomes relevant across multiple conditions), care planning and satisfaction, symptom control by one account,⁹ and by another account cancer stage data, histology, biomarkers, or molecular mutations.³

Key Informant Interviews

We interviewed 7 key informants with expertise in quality measurement, physician accountability, health care reimbursement, oncology, and data standardization. Without prompting, 3 of them explicitly stated that the OCM in its current state fails to capture the patient voice. None described the OCM as adequately patient centered. Two noted the challenge of defining quality when the focus is on process and feasibility, rather than patient outcomes. One notable point was that the lack of meaningful outcomes-based measures of care quality leaves providers concerned about how retrospective payments can be fairly determined, given the underlying characterization of quality care. Most felt the OCM care episode of 6 months from chemotherapy initiation is too short a window for a true capture of relevant patient progression.

When asked how they would define “good” outcomes-based quality measures in oncology, the key informants suggested that these would be actionable (practices or payers intend to act upon results), associated with high costs and interventions that can be implemented to reduce costs, relevant, timely (a difference can be measured within a reasonable window to inform decision-making in an APM), and meaningful to patients. They also recommended, when choosing quality measures more generally, considering whether data are available and capability exists to collect them at reasonable cost and whether the measures will lessen reporting burden on providers.

Multistakeholder Work Group

Fourteen stakeholders representing patient, payer, clinician, clinical guidelines development, managed care, health technology assessment, and industry perspectives made up the work group. Work group members emphasized the lack of a patient voice in current APMs but generally agreed, in discussion, that patient engagement would inevitably filter into quality of care, from research. Most were familiar with core outcome sets (COSs), thus ways in which COSs could improve the patient-centeredness of APMs provided a backdrop for work group discussion. COSs are agreed minimum sets of outcomes that should be measured in all clinical trials for a given condition, set of conditions, or indication.¹⁰

The work group recognized the importance of the measurement timeline in the APM context (noting, for example, that it is infeasible to stipulate payment on survival). Providers in the group acknowledged that clinicians may not accept accountability for certain outcomes-based measures, in which case process-based measures might be more appropriate—highlighting the need for clinician engagement. They also emphasized clinicians’ need to believe that the measures on which they are evaluated are true indicators of care quality and, in the event of poor performance, that there is a way to intervene to see measured improvement. One stakeholder recommended that APMs aspire to connect various measures to “tell a rational quality story” and not just tell providers what to collect, but also help them learn what to do with the data.

Nine of the 14 members completed the online exercise, in which they were asked to rank potential characteristics of outcomes-based quality measures in an APM context (Table). “Clinically relevant” was ranked highest, at No. 1 by 4 of the 9. Clinical experts in the group suggested that providers and clinicians should be engaged to provide meaningful guidance regarding clinically relevant measures for practice. Patients were keen to remind the group that “clinically relevant” does not equal patient relevant. “Meaningful to patients” was ranked No. 1 or No. 2 by 5 members. Four ranked “actionable” as No. 1, No. 2, or No. 3. The term “actionable” was used to describe outcome measures for which interventions or changes to care delivery are feasible and likely to improve those outcomes. “Associated with cost savings” was ranked higher by some payers and providers than others, but low overall.

Synthesis

We suggest a framework to guide deliberations among payers, providers, patients, and other APM stakeholders when selecting outcomes-based measures for future APMs or other value-based payment models (Figure). The proposed framework draws from each step of this exploratory project (literature, interviews, and stakeholder work group). Questions were developed by the project team based on contextual comments from interviews and the work group. Language was drafted internally and then shared with the work group for comment.

DISCUSSION

Value for patients and cost savings within the context of improved patient care should guide targets for APM success,¹¹ as opposed to cost savings alone. With value-based transformation of the entire health care system a top HHS priority, there is a critical need to ensure that the right values are powering this transformation.^12,13 Value should, after all, be defined around the customer: the patient.¹⁴ Although it is encouraging to see pain control, functional status, quality of life, and other future areas of priority for core Medical Oncology Measures,¹⁵ the literature continues to debate how to achieve meaningful quality measures. Process-based measures are easily implementable, but they are no substitute for patient-important outcomes-based measures. The way in which quality is measured in the future should explicitly incorporate the patient perspective, consider patients’ evolving care goals, and help improve shared decision-making.¹⁶ PROs represent an opportunity to do so. Efforts to overcome hurdles to systematically incorporate PROs across health system contexts, including quality improvement, are becoming visible in some clinical areas (eg, depression in primary care).¹⁷ Despite a recognition of the value of PROs in oncology measurement, multiple barriers still exist.² As the feasibility of capturing electronic PROs across health systems improves, we may see additional opportunities to measure what matters in APMs.

Successful APMs and other innovative payment models will also require buy-in from providers of the measures for which they will be held financially accountable.¹⁷ Physicians are increasingly data-driven¹⁸; their buy-in can be a top factor in successful reimbursement initiatives.⁵ Yet they are still not extensively consulted in APM development and are often unable to understand how APMs measure their performance.¹⁹ A recent RAND/American Medical Association report recommends engaging physicians to help simplify APMs and better align financial rewards with improving patient care.²⁰

The proposed framework in the Figure incorporates COSs as potential vehicles for clinical and patient relevance. (Most members of the work group participated in a previous stakeholder discussion on COSs and opportunities for broader uptake in clinical research.²¹) Although the quality of COSs is still somewhat variable, patient engagement and multistakeholder consensus building are central tenets of high-quality COS development, increasingly documented in the peer-reviewed literature.^10,22-25 Furthermore, COS development focuses first on “what” should be measured, before discussing “how”—enabling open discussions about important outcomes first, without being restricted by current feasibility. Greater patient and clinician relevance in quality measures could be facilitated by (1) learning from the stakeholder and patient engagement methods involved in COS development, or (2) where COSs already exist for a condition, looking directly to those outcomes as sources of patient and clinician input. However, published COSs should be considered within the context of the latest methodological standards, before assuming a high degree of patient and clinician relevance.²⁶

Limitations

This exploratory project had several limitations. It was limited in scope: We did not compare other APMs in different therapeutic areas or vet the framework in a broader context. Also, although we engaged a range of stakeholders, the number of participants was small. Further, project questions focused on oncology, thus participants did not explicitly deliberate on criteria for outcomes outside an oncology APM context.

Nevertheless, the proposed framework may help efforts to improve outcomes-based measures in APMs by connecting patient values across the research-care continuum to the decision-making bodies that are responsible for shaping payment policies that ultimately influence the patient experience. For example, as academic and professional groups work toward identifying new core quality measures in oncology,² this framework could serve as a tool to assess and improve patient-centeredness, particularly when initial stakeholder input is limited. A formally vetted version of this framework could potentially be applied to other value-based payment contexts, fostering greater transparency and consistency across value-based initiatives.

CONCLUSIONS

We propose a framework to guide future stakeholder deliberations to identify and select appropriate outcomes-based measures for APMs and other value-based payment initiatives. Although the proposed framework is untested, it offers a stepping stone on the path to clinically meaningful, patient-centered high-value care. Next steps may include a broader review of gaps in APM quality measures across multiple therapeutic areas, additional vetting from a more diverse group of stakeholders, or a formal consensus.

Acknowledgments

The authors thank Harshali Patel and Jeffrey Lemay for helpful comments on an earlier draft of this paper.

Author Affiliations: Center for Medical Technology Policy (RMM, DAM), Baltimore, MD; Rubix Health LLC (SRT), Baltimore, MD; Amgen Inc (ZW), Thousand Oaks, CA.

Source of Funding: The Center for Medical Technology Policy received funding support for this study from Amgen Inc. The authors retained full control over research design, analysis, and findings presented herein. The authors do not report any conflict of interest. This study was an extension of a parent initiative to identify barriers and facilitators of core outcome sets in clinical research that was funded by a precompetitive consortia of life science companies and previously acknowledged (Moloney et al²¹).

Author Disclosures: Mr Wessler is an employee of Amgen Inc. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RMM, DAM, SRT); acquisition of data (RMM); analysis and interpretation of data (RMM, ZW); drafting of the manuscript (RMM, DAM, ZW); critical revision of the manuscript for important intellectual content (RMM, DAM, ZW, SRT); obtaining funding (DAM, SRT); administrative, technical, or logistic support (ZW); and supervision (DAM, SRT).

Address Correspondence to: Rachael M. Moloney, MHS, Center for Medical Technology Policy, 401 E Pratt St, Ste 631, Baltimore, MD 21202. Email: rachael.moloney@cmtpnet.org.

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