During a Sept. 17 panel discussion, Susannah Bernheim, M.D. , M.H.S., chief quality officer and acting chief medical officer with the CMS Innovation Center, described how CMS alternative payment models are evolving to include patient-reported measures.
Bernheim, who was previously senior director of quality measurement at the Yale-New Haven Hospital Centers for Outcomes Research and Evaluation (CORE), was speaking at an Agency for Healthcare Research & Quality meeting about bringing patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) into value-based care.
PREMs such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) are fairly widely used to capture a patient’s experience of an episode of care during an encounter with a health system. They are already widely used in value-based care. PROMs, much less widely used, measure the patient’s health and well-being. They seek to answer the question: Is the patient actually getting better after the care they have received?
Bernheim said this topic fits into a larger CMS quality strategy, a key feature of which is “driving innovations in care that increase the likelihood that people will receive care that's aligned to their goals, values and preferences, and with that, a commitment to using patient-reported performance measures in our models to help achieve that,” she said. “Part of the goals that are set for supporting innovation are increasing the percentage of our models that use at least two patient-reported measures. In some places, we may say patient-reported outcome measures, but we really have a broader strategy incorporating both the concept of patient-reported experiences and PROMs in this goal.”
“Patient-reported measurement can serve two purposes in our model,” she explained. “One is incentives for accountability and improvement for participants who are participating to help them drive improvements and incentives to do so that they are focused on what patients report and need. But just as important is that they can be tools to help us evaluate the model overall.
“We fundamentally believe that bringing patient-reported measures into the model will let us know which improvements matter to beneficiaries,” Bernheim added. “We’re amplifying the voice of patients, helping to drive innovations in care that we hope will increase the likelihood that people receive care aligned with their own goals.”
She gave a few examples from current alternative payment models. In the Kidney Care Choices, model, for example, the Innovation Center is supporting model participants to use tools to assess patient activation and readiness for self-care management, because this is important for slowing the progression of end-stage renal disease.
In Making Care Primary, CMS is trying to build advanced primary care practices that improve the experience, outcomes and equity among many of the practices that are new to value-based care. “Here we're capturing the patient voice through the use of the person-centered primary care measure to promote the transformation of primary care,” Bernheim said.
PROMs critical to include in value-based payment
Also speaking on the panel was Dana Gelb Safran, Sc.D., president and CEO of the National Quality Forum.
She said we now have decades of experience with CAHPs. “I think we can all agree that that has been nothing short of transformational in healthcare organizations today. We have chief patient experience officers; we have significant resources being dedicated in health systems and practices around the country because of the accountability that those organizations have through the CAHPS family of instruments and the public reporting and sometimes the financial incentives attached to those, so we have tremendous debt of gratitude to that team's work and to the way that it has been adopted and implemented. But that said, we've heard significant criticisms of the way that patient-reported experience measures are being used, of the low response rates, of the absence of really leveraging technology in ways that could allow us to get more depth. We're trying to focus on actionability. How do we get to to the real usefulness of these measures? I think that's where the next generation of patient experience measures has a true challenge for how we thread the needle of both the specificity that's needed in performance improvement, a focus on a particular visit, a focus on a particular clinician, together with the breadth that's needed for value-based payment, using the information for public reporting, for payment, where you need a more generalized set of experiences.”
Safran said that PROMs are critical to include in value-based payment, but today are almost never included, especially in ways that measure a patient’s outcome over time to understand: Did patients improve, stay the same or decline in their functional status and well being?
She pointed to several barriers to their wider use. One barrier has been the business case.
“Providers have simply not felt that the amount of work and investment and data that's needed to implement PROMs broadly is called for. Some of what will change that will be payers beginning to incorporate these measures into their value-based payment models. CMMI has committed that by next year, 2025, more than 50% of models will include at least two PROMs,” she said. “That kind of payer action, coupled together with other payers making similar expectations, I think, will begin to address the business case. During my time at Blue Cross in Massachusetts we really saw this with the adoption of PROMs in our network. It was voluntary in the early years and then required as part of the alternative quality contract. That information could provide tremendous new information to guide the evidence base for a given patient with a given functional profile. Would a particular treatment or procedure actually have high probability of success in the patient recovering, or high probability of failure with no change, or worse, yet, a decline in patient functional status?”
That information can be used by those who have accountability for total cost of care, she added, to decide which care is helpful and which care is wasteful, and also to know which alternatives will, in fact, be helpful to patients for whom a given treatment or procedure is not at this time going to be helpful.
“I would say both PREMS and PROMS are absolutely central for value-based payment,” Safran said. “We have a long way to go with both of them to where they can contribute their true, full potential for our value-based payment models.”
A lack of standardization
Greg Meyer, M.D., M.S.c., a professor of medicine at Massachusetts General Hospital and Harvard Medical School and a professor of health policy management at the Harvard Chan School of Public Health, weighed in on why PREMs have taken off and PROMs have not yet.
With patient-reported experience measures, both the government, through CMS, and payers have stepped up and basically declared the standard, Meyer said. “I was around for those discussions when CAHPS became the standard used by CMS. We've not yet had that level of discussion around patient-reported outcomes, and because of that, we are currently suffering because we don't have the standardization that we'd all look for.”
Another issue is comparison data, he said. That involves not only using standard measures, but collecting a robust enough sample size and collecting across enough organizations to have the ability to compare performance. “That is something, again, that has lagged behind where we would all hope,” Meyer said. “Right now, oftentimes those who are out in front with collecting patient-reported outcomes struggle with what do we compare to?
He said another step that needs to happen is that Epic and other EHR vendors have to make it easier for health systems to collect patient-reported outcomes.
Another practical issue, he added, is just the cost. “One of the reasons why patient-reported outcomes have not taken off the way that folks would have hoped is that collecting this information, getting the engagement, and all the rest, all that takes resources. How can we get to the point where there's a trade-off there that actually makes that less cost-prohibitive than it is today?”
The cost of collecting patient-reported experience measures has gone down dramatically. Why is that? “Well, I think standardization played a role for certain. Certainly, there's a lot of motivation in it, because it is something that we get paid on the basis of,” Meyer said. “But in addition to that, there's a vendor community that's developed over time, and there's a competitive marketplace for providing these services that doesn't currently exist for patient-reported outcomes. We haven't yet seen the leverage that comes with a number of vendors who are providing a standard product, but can do so in a competitive manner, in terms of cost to to insurance companies and to delivery systems.”
Meyer said that the default in the way people think about using these measures is for accountability. “That’s important, but frankly, that's not sufficient. Patient-reported outcomes are going to prove to be important for people like me sitting in a primary care office to look to see how we're doing and what we can do better. That's going to help get this adoption moving much, much quicker than it has in the past.”
