Improving patient-reported measures in oncology: a payer call to action.

Despite rising interest in integrating the patient voice in value-based payment (VBP) models for oncology, barriers persist to implementing patient-reported measures (PRMs), including patient-reported performance measures (PR-PMs). This article describes the landscape of oncology PRMs and PR-PMs, identifies implementation barriers, and recommends solutions for public and private payers to accelerate the appropriate use of PRMs in oncology VBP programs. Our research used a multimethod approach that included a literature review, landscape scan, stakeholder interviews and survey, and a multistakeholder roundtable. The literature review and landscape scan found that limited oncology-specific PR-PMs are available and some are already used in VBP programs. Diverse stakeholder perspectives provided insight into filling current gaps in measurement and removing implementation barriers, such as limited relevance of existing PRMs and PR-PMs for oncology; methodological challenges; patient burden and survey fatigue; and provider burden from resource constraints, competing priorities, and insufficient incentives. Key recommendations include: (a) identify or develop meaningful measures that fill gaps, engaging patients throughout measure and program development and evaluation; (b) design programs that include scientifically sound measures standardized to reduce patient and provider burden while supporting care; and (c) engage providers using a stepwise approach that offers resources and incentives to support implementation. DISCLOSURES: Funding for this project was provided by the National Pharmaceutical Council. Schmidt, Perkins, Riposo, and Patel are employees of Discern Health, a consulting firm with many clients, including government, life sciences, nonprofit, and provider organizations. Valuck is a partner at Discern Health. Westrich is an employee of the National Pharmaceutical Council, an industry-funded health policy research group that is not involved in lobbying or advocacy. Basch reports grants from National Cancer Institute and Patient-Centered Outcomes Research Institute; fees from serving as a consultant on research projects at Memorial Sloan Kettering Cancer Center, Dana-Farber Cancer Institute, and Research Triangle Institute/CMS; and fees from serving as a scientific advisor to CareVive Systems, Sivan Healthcare, Navigating Cancer, and AstraZeneca, outside the submitted work. McClellan reports fees from serving on the boards of Johnson & Johnson and Seer Bio and as an advisor to Cota outside the submitted work; and McClellan is an independent board member on the boards of Cigna and Alignment Healthcare, co-chair of the Guiding Committee for the Health Care Payment Learning and Action Network, and receives fees for serving as an advisor for MITRE, outside the submitted work.

Defining current gaps in quality measures for cancer immunotherapy: consensus report from the Society for Immunotherapy of Cancer (SITC) 2019 Quality Summit.

BACKGROUND: Quality measures are important because they can help improve and standardize the delivery of cancer care among healthcare providers and across tumor types. In an environment characterized by a rapidly shifting immunotherapeutic landscape and lack of associated long-term outcome data, defining quality measures for cancer immunotherapy is a high priority yet fraught with many challenges. METHODS: Thus, the Society for Immunotherapy of Cancer convened a multistakeholder expert panel to, first, identify the current gaps in measures of quality cancer care delivery as it relates to immunotherapy and to, second, advance priority concepts surrounding quality measures that could be developed and broadly adopted by the field. RESULTS: After reviewing the existing quality measure landscape employed for immunotherapeutic-based cancer care, the expert panel identified four relevant National Quality Strategy domains (patient safety, person and family-centered care, care coordination and communication, appropriate treatment selection) with significant gaps in immunotherapy-based quality cancer care delivery. Furthermore, these domains offer opportunities for the development of quality measures as they relate to cancer immunotherapy. These four quality measure concepts are presented in this consensus statement. CONCLUSIONS: This work represents a first step toward defining and standardizing quality delivery of cancer immunotherapy in order to realize its optimal application and benefit for patients.

Data Needs for a Serious Illness Care Accountability System: A Framework and Recommendations.

BACKGROUND: Successful implementation of a comprehensive accountability system for community-based serious illness care will require a robust data infrastructure. Data will be needed to support care delivery, quality measurement, value-based payment, and evaluation and monitoring. OBJECTIVE: The specific data needs in these areas need to be identified and understood, so that gaps in currently available data may be addressed. DESIGN: We developed a framework that includes the needed data and data infrastructure to support the features and characteristics of a serious illness care accountability system. Based on this framework, we analyze the current data landscape to identify gaps in available data resources and capacities. This analysis was informed by conducting Internet-based research, interviews with key informants, and a survey of key informants. RESULTS: Based on the identified gaps, we present a series of priority recommendations for advancing the data infrastructure to support community-based serious illness care. These recommendations include additional measurement of patient-reported outcomes, increasing interoperability among various data sources, increasing development and exchange of patient care plans, leveraging newly standardized data on patient functional and cognitive status, and using patient-reported information for clinical decision support at the point of care. CONCLUSION: There are significant unmet data needs for a comprehensive accountability system in serious illness care, but these gaps can be prioritized and addressed through alignment and collaboration across stakeholders.

Accountability for Community-Based Programs for the Seriously Ill.

Innovation is needed to improve care of the seriously ill, and there are important opportunities as we transition from a volume- to value-based payment system. Not all seriously ill are dying; some recover, while others are persistently functionally impaired. While we innovate in service delivery and payment models for the seriously ill, it is important that we concurrently develop accountability that ensures a focus on high-quality care rather than narrowly focusing on cost containment. The Gordon and Betty Moore Foundation convened a meeting of 45 experts to arrive at guiding principles for measurement, create a starter measurement set, specify a proposed definition of the denominator and its refinement, and identify research priorities for future implementation of the accountability system. A series of articles written by experts provided the basis for debate and guidance in formulating a path forward to develop an accountability system for community-based programs for the seriously ill, outlined in this article. As we innovate in existing population-based payment programs such as Medicare Advantage and develop new alternative payment models, it is important and urgent that we develop the foundation for accountability along with actionable measures so that the healthcare system ensures high-quality person- and family-centered care for persons who are seriously ill.

Improving Oncology Quality Measurement in Accountable Care: Filling Gaps with Cross-Cutting Measures.

Payment for health care services, including oncology services, is shifting from volume-based fee-for-service to value-based accountable care. The objective of accountable care is to support providers with flexibility and resources to reform care delivery, accompanied by accountability for maintaining or improving outcomes while lowering costs. These changes depend on health care payers, systems, physicians, and patients having meaningful measures to assess care delivery and outcomes and to balance financial incentives for lowering costs while providing greater value. Gaps in accountable care measure sets may cause missed signals of problems in care and missed opportunities for improvement. Measures to balance financial incentives may be particularly important for oncology, where high cost and increasingly targeted diagnostics and therapeutics intersect with the highly complex and heterogeneous needs and preferences of cancer patients. Moreover, the concept of value in cancer care, defined as the measure of outcomes achieved per costs incurred, is rarely incorporated into performance measurement. This article analyzes gaps in oncology measures in accountable care, discusses challenging measurement issues, and offers strategies for improving oncology measurement. Discern Health analyzed gaps in accountable care measure sets for 10 cancer conditions that were selected based on incidence and prevalence; impact on cost and mortality; a diverse range of high-cost diagnostic procedures and treatment modalities (e.g., genomic tumor testing, molecularly targeted therapies, and stereotactic radiotherapy); and disparities or performance gaps in patient care. We identified gaps by comparing accountable care set measures with high-priority measurement opportunities derived from practice guidelines developed by the National Comprehensive Cancer Network and other oncology specialty societies. We found significant gaps in accountable care measure sets across all 10 conditions. For each gap, we searched for available measures not already being used in programs. Where existing measures did not cover gaps, we recommended refinements to existing measures or proposed measures for development. We shared the results of the measure gap analysis with a roundtable of national experts in cancer care and oncology measurement. During a web meeting and an in-person meeting, the roundtable reviewed the gap analysis and identified priority opportunities for improving measurement. The group determined that overreliance on condition-specific process measures is problematic because of rapidly changing evidence and increasing personalization of cancer care. The group's primary recommendation for enhancing measure sets was to prioritize and develop effective cross-cutting measures that assess clinical and patient-reported outcomes, including shared decision making, care planning, and symptom control. The group also prioritized certain safety and structural measures to complement condition-specific process measures. Further, the group explored strategies for using clinical pathways and devising layered measurement approaches to improve measurement for accountable care. This article presents the roundtable's conclusions and recommendations for next steps. DISCLOSURES: Funding for this project was provided by the National Pharmaceutical Council (NPC). Westrich and Dubois are employees of the NPC. Valuck is a partner with Discern Health. Blaisdell and Dugan are employed by Discern Health. McClellan reports fees for serving on the Johnson & Johnson Board of Directors. Dugan reports consulting fees from the National Committee for Quality Assurance and Pharmacy Quality Alliance. 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. Study concept and design were contributed by Blaisdell, Valuck, Dugan, and Westrich. Blaisdell took the lead in data collection, along with Valuck and Dugan, and data interpretation was performed by Valuck, Blaisdell, Westrich, and Dubois. The manuscript was written by Blaisdell, along with Valuck and Dugan, and revised by Valuck, Westrich, Miller, and McClellan.

Solutions for filling gaps in accountable care measure sets.

OBJECTIVES: A primary objective of accountable care is to support providers in reforming care to improve outcomes and lower costs. Gaps in accountable care measure sets may cause missed opportunities for improvement and missed signals of problems in care. Measures to balance financial incentives may be particularly important for high-cost conditions or specialty treatments. This study explored gaps in measure sets for specific conditions and offers strategies for more comprehensive measurement that do not necessarily require more measures. STUDY DESIGN: A descriptive analysis of measure gaps in accountable care programs and proposed solutions for filling the gaps. METHODS: We analyzed gaps in 2 accountable care organization measure sets for 20 high-priority clinical conditions by comparing the measures in those sets with clinical guidelines and assessing the use of outcome measures. Where we identified gaps, we looked for existing measures to address the gaps. Gaps not addressed by existing measures were considered areas for measure development or measurement strategy refinement. RESULTS: We found measure gaps across all 20 conditions, including those conditions that are commonly addressed in current measure sets. In addition, we found many gaps that could not be filled by existing measures. Results across all 20 conditions informed recommendations for measure set improvement. CONCLUSIONS: Addressing all gaps in accountable care measure sets with more of the same types of measures and approaches to measurement would require an impractical number of measures and would miss the opportunity to use better measures and innovative approaches. Strategies for effectively filling measure gaps include using preferred measure types such as cross-cutting, outcome, and patient-reported measures. Program implementers should also apply new approaches to measurement, including layered and modular models.

Performance measurement for people with multiple chronic conditions: conceptual model.

BACKGROUND: Improving quality of care for people with multiple chronic conditions (MCCs) requires performance measures reflecting the heterogeneity and scope of their care. Since most existing measures are disease specific, performance measures must be refined and new measures must be developed to address the complexity of care for those with MCCs. OBJECTIVES: To describe development of the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model. STUDY DESIGN: Framework development and a national stakeholder panel. METHODS: We used reviews of existing conceptual frameworks of performance measurement, review of the literature on MCCs, input from experts in the multistakeholder Steering Committee, and public comment. RESULTS: The resulting model centers on the patient and family goals and preferences for care in the context of multiple care sites and providers, the type of care they are receiving, and the national priority domains for healthcare quality measurement. CONCLUSIONS: This model organizes measures into a comprehensive framework and identifies areas where measures are lacking. In this context, performance measures can be prioritized and implemented at different levels, in the context of patients' overall healthcare needs.