Measurement For Value-based Payment: Harnessing Patient-Centered Outcomes to Define Quality

On June 24, 2019, President Trump released an Executive Order (EO) seeking to empower patient decision-making by promoting transparency on price and quality. The EO dovetails congressional efforts to pass an omnibus legislative bill, the Lower Health Care Costs Act of 2019, which includes bipartisan provisions aimed specifically at enabling greater transparency in healthcare. In addition to price transparency, the EO directs the Secretaries of Health and Human Services, Defense, and Veterans Affairs to rapidly create a Health Quality Roadmap that aims to align measures reported in federal healthcare programs and “include a strategy for establishing, adopting, and publishing common quality measurements; aligning inpatient and outpatient measures; and eliminating low-value or counterproductive measures.”

The Administration’s call for a Roadmap to be rapidly developed is consistent with a broad consensus among health care stakeholders that existing measures, largely developed within a fee for service (FFS) system, and focused on clinical processes of care are not a good fit for Alternative Payment Models (APMs) that emphasize accountability for cost and outcomes across the care continuum. Many of the measures currently in use in APMs suffer from numerous widely recognized limitations including: 

• Lack of outcomes measures that adequately assess delivery system performance, 

• Undue provider burden, 

• Lack of a systematic approach to retirement of low-value measures, and 

• A focus on point-in-time estimates as opposed to a longitudinal assessment of performance. 

These limitations are widely viewed as a constraint on the long-term ability of APMs to deliver on their promise of value. Consequently, there is a broad consensus on the need for a systematic and concerted effort to develop, test, and adopt the Patient-Centered Outcome Measures (PCOMs) – the next generation of measures - that are better suited for accountability, and that articulate the quadruple aim: better care, better health, lower cost, and reduced provider burden. But despite calls for concerted action, the availability of guiding frameworks, and a better data infrastructure, progress in the development and adoption of PCOMs has been anemic. 

To help catalyze the implementation of PCOMs, The Duke-Margolis Center for Health Policy and leaders formerly with Blue Cross Blue Shield of Massachusetts (BCBSMA) undertook an effort to develop a vision and strategy for the adoption of PCOMS. This effort was informed by a set of convenings of a multi-stakeholder group of experts representing payers, providers, employers, and patients. The convenings focused on a set of important topics including developing a shared vision for PCOMs, discussing key considerations for achieving PCOMs, and a set of specific practical steps to developing/implementing PCOMs. Prior to the convenings, Duke-Margolis conducted interviews with meeting participants to solicit initial feedback on PCOMs and conducted a scan of existing measurement frameworks including the National Academy of Medicine Vital Signs Report and the Healthcare Payment Learning and Action Network (LAN) population-based payment model (PBP) measurement framework, and the Centers for Medicare and Medicaid Services (CMS) Meaningful Measures framework.