By Megan Collado, AcademyHealth
Health care policy wonks and stakeholders have anxiously awaited the proposed rule from the Centers for Medicare and Medicaid Services (CMS) on the value-based payment programs under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Its release on April 27 lays out key parameters for a new Medicare physician payment system aimed at rewarding quality of care rather than quantity and asks experts to share their feedback to inform implementation.
Months prior to the CMS release, AcademyHealth hosted an invitational meeting on the subject of paying for value as part of the Research Insights Project to foster discussion on research evidence among policy audiences who need it to implement health reform. Here are three challenges discussed at the meeting and how the field is working to address them:
Accounting for risk
When faced with sub-par performance evaluations, many physicians respond with: “But my patients are sicker.” Most existing risk adjustment systems fall short of fully explaining patient health status and the likelihood of success for any course of treatment.
An innovative approach to risk adjustment showed promise in a small-practice program in New York in 2009-2010. The Primary Care Information Project (PCIP) furnished electronic health record systems to support a tightly-targeted pay–for-performance intervention. The PCIP adjusted payments upward for patients who were considered more difficult to treat successfully based on a few key indicators: whether they had comorbid conditions and whether they were uninsured or on Medicaid. Results were better in participating clinics than in a control group and also compared favorably with larger practices with similar goals.
Big data can also be a useful tool in identifying patients at risk. Beth Israel Deaconess Medical Center (BIDMC) has worked to use clinical and demographic patient data in an intensive care unit (ICU) safety initiative. After heightening focus on preventable harms, the 650-bed BIDMC has reduced the number of harm events in its ICU from as high as 90 in the second half of 2008 to fewer than 25 per six-month period throughout 2013 and 2014.
Evaluating quality
In a patient-centered era, patient experience has become one of the key measures of quality. But the cost and administrative burden of administering surveys, which often have a low response rate, have led providers to look for additional means of measuring patient experience, such as open-ended narratives.
Physicians often find that written comments from patients are some of the most useful and meaningful forms of patient feedback. The popularity of open-ended formats, such as Yelp and Angie’s List, point to the appeal of narrative evaluations for consumers. Researchers have recently used natural language processing to analyze Yelp reviews of 1,352 hospitals by 17,000 consumers and found that the information may provide a useful complement to surveys such as the Consumer Assessment of Healthcare Providers and Systems.
Determining value
While there are numerous challenges to measuring clinical quality, quality is only one component of health care value. Many questions remain about how best to define value and to measure it.
The Alternative Quality Contract (AQC) is an acknowledged leader in the efforts to effectively integrate cost and quality. Massachusetts’ Blue Cross Blue Shield plan operates the AQC in which contracting providers receive a risk-adjusted global payment for all their attributed enrollees. The payment covers all services and the provider organization is at risk for its contracted share of losses as well as gains. Spending growth rates were reduced by 50 percent in the program’s first four years, showing that provider behavior can be changed with a combination of strong incentives: putting providers at risk for high costs and offering generous rewards for measured quality.
The complexity of the value-based measurement universe goes far beyond these three challenges. Many more issues were discussed at the December Research Insights meeting. For more, read the full Paying for Value issue brief here.
Megan Collado, M.P.H., is a senior manager at AcademyHealth, where she co-directs and supports a number of Robert Wood Johnson Foundation grantmaking programs and is the Project Director of an AHRQ-sponsored conference grant that convenes policy audiences to discuss the evidence and future research needs related to health care costs, financing, organization and markets.