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The American Journal of Managed Care December 2019
Clinical Characteristics and Treatment Patterns Among US Patients With HIV
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Partnering in Postacute Darkness? CMS Has Data That Will Help
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Anne K. Gauthier, MS
Preventive/Office Visit Patient Knowledge and Their Insurance Information Gathering Perceptions
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Cost-Sharing Payments for Out-of-Network Care in Commercially Insured Adults
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Ted A. Skolarus, MD, MPH; Casey A. Dauw, MD; Karen E. Fowler, MPH; Jason D. Mann, MSA; Steven J. Bernstein, MD, MPH; and Jennifer Meddings, MD, MS
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Cost Burden of Hepatitis C Virus Treatment in Commercially Insured Patients
Christine Y. Lu, PhD; Dennis Ross-Degnan, ScD; Fang Zhang, PhD; Robert LeCates, MA; Caitlin Lupton, MSc; Michael Sherman, MD; and Anita Wagner, PharmD
Delivery System Performance as Financial Risk Varies
Joseph P. Newhouse, PhD; Mary Price, MA; John Hsu, MD, MBA; Bruce Landon, MD, MBA; and J. Michael McWilliams, MD, PhD
Association of Care Management Intensity With Healthcare Utilization in an All-Condition Care Management Program
Hussain S. Lalani, MD; Patti L. Ephraim, MPH; Arielle Apfel, MPH; Hsin-Chieh Yeh, PhD; Nowella Durkin; Lindsay Andon, MSPH; Linda Dunbar, PhD; Lawrence J. Appel, MD; and Felicia Hill-Briggs, PhD; for the Johns Hopkins Community Health Partnership
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Outcome Measures for Oncology Alternative Payment Models: Practical Considerations and Recommendations
Jakub P. Hlávka, PhD; Pei-Jung Lin, PhD; and Peter J. Neumann, ScD

Outcome Measures for Oncology Alternative Payment Models: Practical Considerations and Recommendations

Jakub P. Hlávka, PhD; Pei-Jung Lin, PhD; and Peter J. Neumann, ScD
This review presents a set of evidence-based outcome measures for oncology alternative payment models, drawing on evidence from existing and proposed quality measures.

Advantages of Process- and Outcome-Based Measures

Previous scholarship finds that both process- and outcome-based quality measures have advantages and disadvantages (for one such classification, see Table 17).8-10 For example, it is generally easier to generate actionable feedback based on process-based measures and there is mostly no or limited need for risk adjustment (unlike the case for quality measures such as mortality, for which complex case mix, indication, and disease stage adjustments are often required).7 In addition, data collection for process measures is generally faster, can draw on smaller sample sizes, and does not require advanced statistical analysis to yield practical results.7

On the other hand, outcome measures are generally based on clinical end points with proven significance in the quality of care. They are more understandable by patients and nonclinicians and are easier to define comprehensively (eg, hospice admissions for at least 3 days prior to death).7 Relatedly, an improvement in process measures may be a useful step in care coordination but may not always have an observable effect on improvement in clinical outcomes, especially when included for billing purposes only.11 Given these realities, the Agency for Healthcare Research and Quality regards outcome-based measures as the “gold standard” in quality measurement.12 Expert groups such as the Healthcare Association of New York State suggest that “regulators and payers should focus on overall performance (outcome measures), and defer the operations and use of process measures for internal quality improvement by healthcare providers.”13

Process-based measures dominate the OCM and other oncology quality assessment frameworks, yet outcome-based measures have an important role to play. Outcome-based measures are directly connected to real-world outcomes, ranging from hospital admissions to mortality and patient-reported outcomes (PROs), reflecting what patients and providers care about most.

Outcome Measures in Existing Oncology Quality Frameworks

Of the 142 quality measures from 7 oncology quality assessment frameworks that we reviewed, 80.3% (n = 114) were process-based measures and 19.7% (n = 28) were outcome-based measures. An earlier analysis of the National Quality Measures Clearinghouse found an even lower proportion of outcome-based measures (7.1%) based on a total of 1958 quality indicators from a wide range of therapeutic areas.11 Of those nearly 2000 indicators, only 1.6% were patient-reported outcome measures (PROMs).11

We condensed the 28 outcome-based measures into 23 unique outcome measures by merging identical or near-identical measures and grouping them into 5 categories: (1) admissions and hospital visits (including emergency department [ED] visits), (2) hospice care, (3) mortality, (4) PROs, and (5) adverse events (AEs) (Table 2).

Admissions and hospital visits. Admissions and hospital visits, after risk adjustment, are important indicators of the appropriateness and timeliness of care. Up to 50% of ED visits are related to complications from chemotherapy, which can potentially indicate suboptimal management of the disease and care coordination (ranging from information sharing among providers to education about end-of-life care).14

The significant variation observed in admission rates and hospital/ED visits between different providers, even when controlling for other factors, has spurred research related to avoidable hospitalizations and appropriateness of care, especially in late-stage cancer care.15 In 2016, for example, CMS announced the inclusion of inpatient admissions and ED visits for patients receiving outpatient chemotherapy in its Hospital Outpatient Quality Reporting Program.16 Including hospital visits in payment models aims to “encourage reporting facilities to take steps to prevent and improve management of side effects and complications from treatment.”17

Hospice care. Although it offers patients, caregivers, and the healthcare system advantages relative to hospital settings, hospice care is generally underutilized. Quality measures related to hospice care may improve the quality of life of patients with late-stage cancer, reduce spending, and reduce burden among providers and caretakers.

Allowing patients with cancer to receive palliative care in a hospice setting is traditionally associated with improvements in quality of life, as well as system efficiencies. Yet, up to 66% of patients with cancer are not enrolled in hospice in the last 30 days of life, and less than 29% are enrolled for at least 2 months (considered appropriate care), based on an international review of 78 studies published between 1998 and 2011.18 One factor explaining the suboptimal transition to palliative care may be doctors’ tendency to overestimate survival prospects of a patient.19 Hospice-related measures aim to reduce wasteful spending on care that is unlikely to improve clinical outcomes and to provide patients with a higher quality of life. Specific provisions may be needed for palliative chemotherapy and other treatments that can extend the length of life while in palliative care.

Although outcome-based measures in this domain tend to focus on hospice settings alone, recent discussions suggest that palliative care may improve patient quality of life if initiated earlier in the cancer treatment course.20,21 In 2012, the National Quality Forum endorsed 14 measures related to end-of-life care, of which several are outcome-based, including “comfortable dying” and bereaved family survey measures.22 Finally, patient- and caregiver-reported outcomes may have a more prominent role to play, as end-of-life care should reflect patient and caregiver preferences.23

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