During a panel discussion on September 17, Susannah Bernheim, MD, MHS, chief quality officer and interim medical director of the CMS Innovation Center, described how CMS’s alternative payment models are evolving to include patient-reported measures.
Bernheim, who previously was senior director of quality measurement at the Centers for Outcomes Research and Evaluation (CORE) at Yale-New Haven Hospital, spoke at an Agency for Healthcare Research and Quality meeting about how to lead patient-reported experience measures (PREM) and patient. -reported outcome measures (PROM) in value-based care.
PREMs, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS), are used quite frequently to capture a patient’s experience in an episode of care during an encounter with a healthcare system. They are already widely used in value-based care. Much less used, PROMs measure patient health and well-being. They seek to answer the question: is the patient really improving after the care they have received?
Bernheim said this theme fits into CMS’s broader quality strategy, a key feature of which is to “drive innovations in care that increase the likelihood that people will receive care that is aligned with their goals, values and preferences, and with that, a commitment to using patient-reported performance measures in our models to help achieve this,” he said. “Part of the goals they set to support innovation is to increase the percentage of our models that use the patient. minus two patient-reported measures. In some places, we can say patient-reported outcome measures, but we actually have a broader strategy that incorporates both the concept of patient-reported experiences and PROMs in this objective.”
“Patient-reported measurement can serve two purposes in our model,” he explained. “One is accountability and improvement incentives for participating participants to help them drive improvements and incentives to focus on what patients report and need. But equally important is that they can be tools that help us evaluate the model in general.
“We fundamentally believe that incorporating patient-reported measures into the model will allow us to know what improvements are important to beneficiaries,” Bernheim added. “We are 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.”
He gave some examples of 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 to manage self-care, because this is important to slow the progression of the disease. end-stage kidney disease.
In Making Care Primary, CMS is seeking to create advanced primary care practices that improve experience, outcomes, and equity among many of the practices that are new to value-based care. “Here we are capturing the patient voice by using the person-centered primary care measure to promote the transformation of primary care,” Bernheim said.
It is essential to include PROM in value-based payment
Also speaking on the panel was Dana Gelb Safran, Sc.D., president and CEO of the National Quality Forum.
He said we now have decades of experience with CAHP. “I think we can all agree that this has been nothing short of transformative in today’s healthcare organizations. We have patient experience directors; We have significant resources dedicated to health systems and practices across the country because of the accountability those organizations have through the CAHPS family of instruments and public reporting and sometimes the financial incentives associated with them, so we have a huge debt of gratitude for that. the team’s work and the way it has been adopted and implemented. But having said that, we’ve heard significant criticism about the way patient-reported experience measures are used, about the low response rates, about the failure to really leverage technology in a way that allows us to dig deeper. We are trying to focus on actionability. How do we arrive at the real usefulness of these measures? I think that’s where the next generation of patient experience measures presents a real challenge in terms of how to thread the needle of the specificity that’s needed to improve performance, a focus on a particular visit, a focus on a particular physician. , along with the breadth needed for value-based payment, using the information for public reporting, for payment, where a more generalized set of experiences is needed.”
Safran said it is critical to include PROMs in value-based payment, but these days they are almost never included, especially in ways that measure a patient’s outcome over time to understand: Did patients get better, did they stay the same? or decreased in their functional status and well-being? ?
He noted several barriers to its wider use. One barrier has been the commercial argument.
“Vendors simply haven’t felt the amount of work, investment and data required to implement PROMs broadly. Some of what will change is that payers will begin 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,” he said. “I think that type of action by payers, along with other payers who have similar expectations, 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 was later required as part of the alternative quality contract. That information could provide tremendously new information to guide the evidence base for a given patient with a given functional profile. Would a particular treatment or procedure really have a high probability of success in the patient’s recovery, or a high probability of failure with no change, or worse, a decrease in the patient’s functional status?
That information can be used by those responsible for the total cost of care, he added, to decide what care is helpful and what is wasteful, and also to know which alternatives will, in fact, be helpful to patients for whom particular care The treatment or procedure will not be helpful at this time.
“I would say that both PREMS and PROMS are absolutely critical to value-based payment,” Safran said. “We have a long way to go with both of them so they can contribute their true and full potential to our value-based payment models.”
Lack of standardization
Greg Meyer, MD, MSc, professor of medicine at Massachusetts General Hospital and Harvard Medical School and professor of health policy management at the Harvard Chan School of Public Health, weighed in on why PREMs have taken off and PROMs 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 present at those discussions when CAHPS became the standard used by CMS. “We haven’t had that level of discussion about patient-reported outcomes yet, and because of that, we are currently suffering because we don’t have the standardization that we would all seek.”
Another problem is comparative data, he said. That means not only using standard measures, but also collecting a sufficiently robust sample size and collecting data from enough organizations to have the ability to compare performance. “That’s something, again, that’s fallen behind what we all expected,” Meyer said. “Right now, often those at the forefront of collecting patient-reported outcomes struggle with what do we compare ourselves to?”
He said another step that needs to be taken 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 simply cost. “One of the reasons patient-reported outcomes haven’t taken off like people would have hoped is that collecting this information, getting buy-in and everything else, all of that takes resources. How can we get to the point where there is a trade-off that actually makes the cost less prohibitive than it is today?”
The cost of collecting measures of patient-reported experience has been dramatically reduced. Why is that? “Well, I think standardization certainly played a role. There’s certainly a lot of motivation in it, because it’s something we get paid to do,” Meyer said. “But in addition to that, there is a community of providers that has developed over time and there is a competitive market for providing these services that currently does not exist for patient-reported outcomes. “We haven’t yet seen the leverage that comes with a bunch of vendors offering a standard product, but we can do it competitively, in terms of cost to insurance companies and to delivery systems.”
Meyer said the default way people think about using these measures is accountability. “That’s important, but, frankly, it’s not enough. Patient-reported outcomes will be important for people like me, sitting in a primary care office, to see how we are doing and what we can do better. “That will help this adoption move much, much faster than in the past.”
