Aligning Around Value: Challenges With Quality Measures and Implementing Clinical Nuance

Laura Joszt

Awareness isn’t enough in the move to value-based care—the right infrastructure and culture need to be in place in healthcare organizations, said panelists during the VBID Summit, held March 14 by the University of Michigan Center for Value-Based Insurance Design (V-BID).

During the panel, “Aligning Clinicians and Consumers Around Value,” panelists Kavita Patel, MD, Brookings Institute; Michael E. Chernew, PhD, Harvard Medical School; and Katy Spangler, Spangler Strategies discussed implementing the VBID concept in health policy and payment models, challenges with quality measurements, the role of employers in value-based care, and more.

As the practicing clinician on the panel, Patel provided insight into the challenges facing those treating patients as the industry tries to move to value-based care models. Even as someone who does work in the policy space, Patel admitted that she and her fellow employed physicians in a Medicare Shared Savings Program accountable care organization (ACO) don’t “have any clue.”

“The alignment around value-based models is clunky, at best,” she said. Adding that quality measurement is a problem.

“There is a state of disarray in the measures I have to report on, and now we’ve added MACRA [Medicare Access and CHIP Reauthorization Act] on top of that, because, unfortunately, the [alternative payment models] I’m in don’t get me out of that traditional reporting,” Patel explained.

What is going to create change isn’t necessarily having payment mechanisms in place to push value-based care, though. Patel highlighted the Camden Coalition of Healthcare Providers, which, under former leader Jeffrey Brenner, MD, launched an effort to improve care for high-need patients. Looking at successful organizations like Camden Coalition, it becomes clear that being successful is really about having the infrastructure and the right culture in place.

“It’s much more about the fact that you have someone like Jeff Brenner who said, ‘Wow, care for these people sucks; let’s do better,’ not because they have a great contract,” Patel said. “It helps when you have a great contract, but it doesn’t affect change.”

Chernew added that there is a disconnect between the people who make decisions.

“The organizations and people who are making decisions around benefit design are often different than the people and organizations making decisions around payment,” he said.

Spangler echoed the point that people need to be on the same page. She explained that there have been employers who have tried to find the kind of system that the California Public Employees' Retirement System, known as CalPERS, has with its reference pricing program through their own reference-based pricing or direct contracting with ACOs, but “it only gets you so far,” she said. What needs to happen is that the health plans and the rest of the community needs to get on the same page.

“Everyone has to come together to advance the ball,” because making real change is hard to impossible if it’s just CMS or Aetna doing the work, Spangler said.

Chernew noted that initiatives like reference-based pricing—a program in which employers set a pricing cap on the amount they will cover for certain services, and employers who choose a more expensive service pay the excess amount—haven’t really taken off because the ideas seem good until they need to be implemented.

“Everyone wants to be disruptive and do a better job until they have to be disruptive and change the system, and then they don’t,” he said. For instance, when Harvard considered reference-based pricing, it was enthusiastic “until we realized someone really would have to pay that extra out of pocket.”

The panelists also took time to discuss the failings of the current quality measurements system. Spangled explained that the industry needs to, at a minimum, set uniform quality measures, and Chernew agreed that there needs to be a streamlined and smaller quality measurements system.

Patel explained that the measures may actually be getting in the way of quality. She explained that she has 3 different ways to measure blood pressure depending on who the payer is. “I think that’s a very clear example where that doesn’t make any sense,” she said. “That’s the kind of harmonization that we seek.”

Instead, doctors are left to make a financial calculation and decide how much they care about performing well on those measures based on the population they treat, she explained.

“There’s no doctor, including myself, that would like to say, ‘I deliver bad quality,’ but we’ve got to choose what to pay attention to—medical wellness visits, chronic care management, transitional care management, advanced care planning—it’s exhausting,” Patel said.

The topic of clinical nuance, a key tenet of the VBID model, was also discussed. The challenge with clinical nuance is designing a benefit for it. Patel explained that diabetes is one of the poster children for clinical nuance, because there are a lot of therapies, and some of the newer ones also do things like reduce obesity, but they are very expensive. However, as the clinician, she knows which patient should be on which therapy based on what they’ve already tried or what other health issues the patient has. The problem is that, from a payer side, all of that is difficult to see from a claim.

Chernew admitted that nuance is complicated to get to work, and more often than not, it won’t. In addition, communicating clinical nuance to consumers and how it fits into the benefit design is a daunting task, Chernew and Patel agreed.

“Communicating [nuance], it’s a nightmare to try to put it in black and white. But it’s not impossible,” Patel said.
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