News

QURE Moves to San Francisco

QURE Healthcare has moved its headquarters to San Francisco! Our new home will be located at 450 Pacific Ave in the historic Jackson Square District of San Francisco.

We look forward to welcoming friends, partners and clients in our new home.

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Dr. John Peabody Presents at the World Bank on Quality of Care

On September 17th, Dr. John Peabody presented at a World Bank Brown Bag Lunch co-hosted by RBF Health. The topic for the BBL was improving the quality of healthcare around the globe. Dr. Peabody highlighted the need for additional studies on quality of health services and the necessity to measure physician skill where improvement is needed.

RBF Health provided an additional description of the event:

“While universal health care has certainly not been attained in all LMICs, better access and utilization have revealed striking gaps in the quality of health care that is provided. This raises the very worrisome practicality that “access to poor quality of health services may be no better than no access at all.”  Raising the quality of health care, however, is arguably even more challenging than increasing access or other structural elements of care, such as drugs, equipment, and facilities.

Research and policy in the past decade have revealed the depth of this problem and illuminated some possible solutions. Quality of care criteria, for example, is increasingly available from the evidence-based literature. Measurement against those criteria, at a systemic level, is gradually being expected. ”

For more information on the event: https://www.rbfhealth.org/event/quality-health-care-link-between-universal-coverage-and-health-outcomes#sthash.xGLSupXk.dpuf

 

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Dr. John Peabody Presents on Quality of Care at COHRED Event

On August 25th, 2015, DCP3 authors Dr. John PeabodyRohina Joshi, and Barbara McPake, as well as DCP3 advisory committee member Jaime Montoya, presented at COHRED’s 2015 Global Forum on Research and Innovation for Health in Pasay City, Philippines. Dr. Peabody presented on updates regarding the quality chapter of DCP-3 and the QIDS Project.

Playing to a packed house of over 400 participants, DCP3 contributors spoke on themes of quality of care and quality improvement in low- and middle-income countries, themes which occur across DCP3 volumes and topics.

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For more information on DCP-3 and COHRED: http://dcp-3.org/

Value-Based Pricing for Pharma Gets a Shot in the Arm

Patients, employers and payers are increasingly feeling the pressure of rising drug costs. As one example of this pressure, a 2015 study in the Journal of Economic Perspectives found that oncology drug prices have increased by an average of $8,500 every year over the past 15 years. In response, insurers, providers and prescription benefit managers are now pushing back in creative ways. The prices for drugs, they argue, should be based on how well the drug works and the demonstrated value it provides. Express Scripts and Memorial Sloan Kettering are two organizations innovating new ways to evaluate the clinical utility of different drugs and price them accordingly.

Express Scripts, a large manager of prescription-drug benefits for U.S. employers and insurers, announced in May that it is developing a new system in which payments for cancer medications would vary based on how well the drug works. Currently, a drug’s price remains the same regardless of the condition it is being used to treat or the efficacy it has in a given indication. This new program would result in indication specific pricing where drugs that are more efficacious would garner higher payments than those that are less so. Approaches like this are not unheard of and have been applied in Europe. This push by Express Scripts, however, has the potential to disrupt US drug pricing and will put additional pressure on drug companies to demonstrate clinical utility that supports value-based prices.

In an effort to tackle some of the same issues, Memorial Sloan Kettering Cancer Center has developed a new online tool called DrugAbacus, which brings some transparency to the various costs and benefits of 54 different cancer drugs. The tool uses data submitted for FDA approval to model costs associated with factors like efficacy and toxicity to arrive at an estimated value-based price.

In an interview with the Wall Street Journal, Director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center, Dr. Peter Bach said prices for many new cancer drugs don’t reflect their value to doctors and patients. “Right now, manufacturers have total price control, and total control of prices has led to irrational pricing behaviors,” he said. The DrugAbacus tool is designed to model value-based drug pricing and provide a more accurate picture of the clinical utility of a drug. An example of significant price differences using value-based pricing is Eli Lilly’s Erbitux (cetuximab), which is much less effective in advanced head and neck cancer than it is in colorectal cancer. Right now, the price of the drug is the same in both indications, but the DrugAbacus tool estimates that the current $10,320 price would drop to only $470 when used in head and neck cancer.

Pay-for-performance pricing and cost transparency are sweeping health care and hitting drug companies, life science vendors, health systems and providers in unique ways. The overall take-home, however, is that the old ways of doing business and charging for care will not be sustainable going forward. Demonstrating cost-effectiveness and clinical utility to payers and patients alike is no longer optional.

 

Sources:

Howard, David H., Peter B. Bach, Ernst R. Berndt, and Rena M. Conti. 2015. “Pricing in the Market for Anticancer Drugs.” Journal of Economic Perspectives, 29(1): 139-62.

Loftus, Peter, “New Push Ties Cost of Drugs to How Well They Work,” Wall Street Journal, May 26, 2015. Accessed June 25, 2015. 

Loftus, Peter, “How Much Should Cancer Drugs Cost?”, Wall Street Journal, June 18, 2015. Accessed June 25, 2015. 

 

ACOs Work, but New Tools and Approaches Are Needed

At QURE, we get up every morning because we believe in our mission to improve health care quality and reduce costs through measurement and feedback. We’ve naturally been excited by the growing body of literature showing that new payment models providing financial incentives for achieving these twin goals have a real impact.

In June of this year, Nyweide and colleagues at CMS added important additional evidence that properly aligned incentives lead to reduced cost without sacrificing quality. In JAMA, they reported results from the first two years of Medicare’s Pioneer ACO program, covering 2012 and 2013. As a brief reminder, the Pioneer ACO program is structured such that participating organizations that care for their patients at a lower total cost than expected receive a portion of those savings as direct payments. To receive the shared savings payments, however, organizations must also meet specific quality and patient experience thresholds. Compared to the more common Medicare Shared Savings Program (MSSP), the Pioneer ACOs have the opportunity for greater financial upside, but, as of 2013, the responsibility to also share in losses if spending exceeded targets.

We found three key take-aways from this latest report:

  1. We can reduce spending without sacrificing quality or experience

The headline from the study is that the 32 Pioneer ACOs saved a total of $385M in 2012 and 2013, when compared to similar groups of patients not attributed to one of the ACOs. It’s not often that programs can claim saving hundreds of millions of dollars. Not surprisingly, reductions in inpatient spending showed the largest cost savings, and decreases were also seen in physician services, ED and post-acute care. Importantly, quality measures did not suffer and Pioneer ACO patients even reported higher satisfaction with access to timely care and clinical communication.

  1. Achieving savings is hard

The aggregate numbers above are impressive, but the Pioneer ACO experience also shows that achieving and sustaining these savings is difficult work. First, most of the savings was realized in the first year. After achieving $280M in savings in 2012, this total fell to $185M in 2013, suggesting that finding savings after targeting the initial low-hanging fruit is more difficult. Second, 13 of the original 32 participants have left the program. Many of the departures were from organizations that were unable to achieve or sustain savings.

  1. There is much more to do

The numbers reported here are trivial when compared to Medicare’s nearly $600 billion annual spend, but they do represent a 4% reduction in spending that, if extended nationwide, would go a long way in “bending the cost curve.” Recognizing this, CMS has announced that they will expand the Pioneer model to other organizations. However, given the struggles many of the hand-picked, well-established early Pioneer participants faced, it is clear that others moving down this road must be thoughtful and deliberate about the tools and strategies they employ.

Driving these savings in a sustainable way, without sacrificing quality, will require multiple approaches including better patient engagement, big data analytics and tighter integration across the care continuum. Most importantly, it will also require directly involving providers around evidence-based care that reduces unwarranted variation. At QURE we have proven that engaging clinicians with Clinical Performance and Value (CPV®) vignettes supports cost savings efforts within ACOs. As one example, our recently published work with the Providence Medical Group demonstrates nearly $800,000 in annual savings opportunities across just 24 cardiology providers.

QURE continues to generate exciting evidence that measuring care practice and engaging providers around variation reduction is essential to realizing the twin goals of high quality and low cost. These goals will increasingly define success as new payment models, like the Pioneer ACO, become more and more common across the country.

Sources: Nyweide DJ, et al. Association of Pioneer Accountable Care Organizations vs Traditional Medicare Fee for Service With Spending, Utilization, and Patient Experience JAMA. 2015; 313(21):2152-2161.

Peabody JW, et al. Managing Specialty Care in an Era of Heightened Accountability: Emphasizing Quality and Accelerating Savings. Am J Manag Care. 2015;21(4):284-292

QURE Announces the Arrival of David Paculdo

QURE Healthcare is very pleased to announce the appointment of David Paculdo MS, as Director of Analytics and research. David comes to QURE with a strong background in data analytics and public health. David will continue to bolster QURE’s data analysis capabilities and ensure continuation of a robust literature pipeline continuing to validate the CPVs.

As Director of Analytics and Research at QURE Healthcare, David will be primarily responsible for planning and executing data analyses related to QURE’s core business, as well as guiding and overseeing the overall analytics and statistical modeling projects of the analytics team.

David received his Master of Public Health from Dartmouth College in 2003, with an emphasis in quality improvement and biostatistics, and a Bachelor of Science in Electrical Engineering from the University of California, Irvine. He has over ten years of experience related to healthcare analysis and outcomes, and he has been a contributing author to over a dozen peer-reviewed articles.

Prior to joining QURE, David worked in semiconductor technology at IBM, where he fulfilled several technical and information technology roles for US and international clients to enable the success of a multiple projects.

“As QURE growth accelerates, David comes to us at a critical time to oversee and build our analytics team.  Joined by our current analysts in our San Francisco and Manila offices, David will lead the team and the critical interface between measurement data and performance analytics,” said Dr. John Peabody, QURE’s President and Founder. “David’s extensive programming and statistical experience means QURE will refine our industry leading approach and scale our reach to QURE’s clients and strategic partners.”

David described his addition to the QURE team by saying, “I am delighted to join such a fast growing company involved in one of the most important challenges facing health care:  improving the quality of care.  Patients everywhere want their doctors to be supported as well as accountable and I think QURE’s CPV technology does this in a unique, powerful and effective way.”

Managing Specialty Care in an Era of Heightened Accountability: Emphasizing Quality and Accelerating Savings

Engaging specialists in accountable care organizations (ACOs) is a challenge that has not been addressed by many health systems or payers. A novel accountable care design among a group of cardiologist was published today in the American Journal of Managed Care.

ACOs increasingly rely on risk-based contracting to avoid over-provision of services under fee-for-service arrangements. However, under-providing necessary services maybe an unintended consequence of global budget or pre-payment schemes.  To guard against this, the Cardiology ACO design project, called ACT-C3 and led by Dr. John Peabody, President of QURE Healthcare and Dr. Xiaoyan Huang, Cardiologist at Providence Health System, introduced an approach whereby the shared savings payment was conditioned upon reaching a series of practice based quality standards.  Standards were set using a well-established quality measurement and feedback system, called Clinical Performance and Value (CPV®) vignettes. In this study, CPVs measured clinical practice variation in treating coronary heart disease (CHD), coronary heart failure (CHF), and atrial fibrillation (AF).

In collaboration with the Providence Medical Group, in Portland, Oregon, cardiologists and advanced practice practitioners completed a set of cardiology CPVs. Then, drawing upon claims data from 2009 through 2011, QURE and Providence then created a historic budget to capture cardiovascular disease (CVD)-related costs for attributed patients on a per patient per year basis. This budget identified a spending target and the shared savings that would be realized if quality targets – based on the CPVs – were met.

At baseline, CPV quality scores measured against evidence-based cardiology guidelines, ranged from 48.9% to 85.4% (mean = 66.8%; SD = 5.4%), and the prevalence of unnecessary testing was 46% in CHD, 71% in CHF, and 30% in AF.  The authors then determined the potential savings from the specialty ACO design.  Forecasts showed that if unnecessary care were reduced by 15% to 25% using CPV measurement and feedback to reduce variation in care practice, there would be a savings of $200,000 to $498,000 ($50-$83 per patient visit) annually. In addition, when they targeted the top 10% most expensive providers as determined by CVD-related costs and reduced their spending by 25%, savings would result in an additional $283,512 in savings per year.

“We believe our study at Providence will have significant implications for a large number of ACOs and similar organizations as they begin to bring specialists into their ACOs”, said Dr. Peabody. “As much as 70% of all health care spending is specialty based and the model we designed at Providence shows how shared accountability can lead to higher quality and dramatically lower costs.”

About QURE Healthcare

QURE Healthcare is a research and business strategy firm committed to improving the quality of clinical care. QURE uses its proprietary software technology, CPV® (Clinical Performance and Value) vignettes, to evaluate clinical practice and the cost-effectiveness of health care services at the level of individual physicians and other health care providers. CPV® vignettes are used in health systems in the US and over 30 countries worldwide. Core services include CPV® studies, health economic analyses, and physician-level data collection. The ease, validity and affordability of CPV® vignettes attract a wide array of clients: payers, hospital systems, life science firms, medical technology companies, medical licensing and education institutions as well as international health development organizations. For more information visit LinkedIn (https://www.linkedin.com/company/qure-healthcare), Twitter (https://twitter.com/QURE_Healthcare) or the QURE homepage (http://www.qurehealthcare.com).

 

About the Journal

The American Journal of Managed Care, now in its 20th year of publication, is the leading peer-reviewed journal dedicated to issues in managed care. Other titles in the AJMC family of publications are The American Journal of Pharmacy Benefits, which provides pharmacy and formulary decision makers with information to improve the efficiency and health outcomes in managing pharmaceutical care. In December 2013, AJMC introduced The American Journal of Accountable Care, which publishes research and commentary devoted to understanding changes to the healthcare system due to the 2010 Affordable Care Act. AJMC’s news publications, the Evidence-Based series, bring together stakeholder views from payers, providers, policymakers and pharmaceutical leaders in the areas of oncology, diabetes management, and immunology and infectious disease. To order reprints of articles appearing in AJMC publications, please call (609) 716-7777, x 131.

 

QURE Healthcare Announces Launch of Orthopedic Care Transformation Project

San Rafael, CA – QURE Healthcare, a leader in quality measurement and clinician engagement, announced the completion of the first round of a year-long practice pattern measurement and feedback project with a large, multi-hospital system in the Midwest. The health system is using QURE’s Clinical Performance and Value (CPV®) vignettes to engage orthopedic surgeons around quality improvement and variation reduction. This level of physician engagement will complement the ongoing efforts of the health system to succeed in new payment models by delivering high-quality, high-value care.

Working with a group of elite orthopedic surgeons, QURE has deployed its CPV® vignette system, a set of validated virtual patient cases and corresponding evidence-based feedback system. The CPV® system measures current practice patterns, identifies opportunities to reduce variation, and directly engages physicians to enhance the system’s value-based care capabilities.

“It is an honor to be working with health care innovators who are committed to delivering the highest quality and best value to patients,” said Dr. John Peabody, president of QURE Healthcare. “We look forward to a long-term partnership that will create sustainable care transformation by directly engaging specialists in data-driven discussions about quality, practice variation and the cost of care.”

***

About QURE Healthcare

QURE Healthcare is a research and business strategy firm committed to improving the quality of clinical care. QURE uses its proprietary software technology, CPV® (Clinical Performance and Value) vignettes, to evaluate clinical practice and the cost-effectiveness of health care services at the level of individual physicians and other health care providers. CPV® vignettes are used in health systems in the US and over 30 countries worldwide. Core services include CPV® studies, health economic analyses, and physician-level data collection. The ease, validity and affordability of CPV® vignettes attract a wide array of clients: payers, hospital systems, life science firms, medical technology companies, medical licensing and education institutions as well as international health development organizations. For more information visit LinkedIn (https://www.linkedin.com/company/qure-healthcare), Twitter (https://twitter.com/QURE_Healthcare) or the QURE homepage (http://www.qurehealthcare.com).

 

Quality Remains Top of Mind in 2015

Changing provider payment models and poor quality metrics continued to grab headlines in 2014, and we anticipate these topics will keep everyone’s interest in 2015.  At the end of the year, good news came when the Department of Health and Human Services (HHS) released a report noting 50,000 fewer patient deaths in hospitals and $12 billion in health care savings[1],[2] due in part to Medicare payment incentives created under the ACA to improve quality of care.

This good news, however, may not really be news at all. CMS, amazingly, allowed each hospital to define its own performance, using their own clinical or administrative data. This means there is no standardized or validated performance measures across the participating hospitals, obviating the chance for real comparisons across facilities and systems over time. We also know well that administrative data can be an unreliable source of clinical information. The inconsistent use of metrics across hospitals not only puts into question the rigor of the evaluation, but it also challenges the applicability and scalability of performance incentive programs across hospitals and networks[3].

Like hospitals, physician pay is also increasingly tied to performance indicators and measures of quality. In a recent survey, released by the Medical Group Management Association (MGMA), primary care physicians and specialists reported that their total compensation tied to measures of quality had grown to 6%. We believe the appeal of rewarding higher quality is here to stay, and will accelerate as providers are measured against standards even while shifting to alternative care delivery models.  With this, we hope to also see a heightened interest in identifying performance metrics that are meaningful and can be compared across settings.  Christine Cassel and her co-authors presented a similar perspective a few weeks ago in the NEJM[4] where they cited evidence of very little overlap (in one case, just 20%) between performance measures used across measurement programs in the U.S. They also lamented the continued use of measures that do not have a demonstrated impact on health outcomes.  We are hopeful that in this coming year we will see thoughtful focus on the quality measures matter the most and hard thoughts on how these measures are linked to provider performance incentive programs.

We reflect below on two well-known case stories– the Premier Hospital Quality Incentive Demonstration and the Medicare Physician Group Practice Demonstration – to offer some ideas on how incentive programs might better leverage the power of combining meaningful metrics with feedback and education.

 

Case Study 1: The Premier Hospital Quality Incentive Demonstration

In 2003, the Premier Hospital Quality Incentive Demonstration began offering financial incentives tied to performance measures related to five common conditions (27 measured processes and seven measured outcomes). However, independent studies and the Congressional Budget Office (CBO) concluded in 2012 that the Premier demonstration showed only temporary improvements in quality, as measured by 30-day mortality rates, and had no significant impact on Medicare spending[5].

 

What went wrong? The first three years of the demonstration tested whether quality could be improved if incentives were offered to those whose quality scores were in the top 20 percent; participants were only rewarded for attainment, not for improvement.  Importantly, there was also no measurement feedback offered. CMS provided the participants with feedback on scores approximately 12 months after year’s end and distributed bonus payments 3 months after that. The lack of real-time feedback likely did not allow enough time for providers to react and for serious behavior/cultural changes to improve quality.

Case Study 2: The Medicare Physician Group Practice Demonstration

The Medicare Physician Group Practice Demonstration ran from 2005 to 2010 among ten large physician group practices who were paid incentives when they met quality targets and achieved lower cost growth than local controls. At the end of the project, there was a demonstrated improvement in quality and reductions in spending growth for most Medicare beneficiaries. Cost reductions were greatest for the 15 percent of patients who were dual eligibles, typically low-income people who qualify for both Medicaid and Medicare and who often have complex, chronic conditions. Of the 10 programs, however, only two qualified for the bonus, including the Marshfield Clinic.

What worked? Those that succeed in the program did so by focusing on most expensive place to treat patients (the hospital) and the most expensive patients (complex, chronically ill and vulnerable)[6]. Providers were measured based on clinical factors related to care coordination and disease management while being provided with timely data around the use of care. Theodore Praxel of the Marshfield Clinic credited their program’s success to “care management programs, and education and feedback to providers regarding populations of patients with a given condition.[7]

Measurement, Feedback and Education Key to Success?

By and large, rewards succeed at securing one thing – temporary compliance, as already observed in a number of failed projects like the Premier Demonstration. Incentives, a version of what psychologists call extrinsic motivators, have little effect on the attitudes that influence behavior. They may not create a long-term commitment to any value or action, but only temporarily change what we do.  Alfie Kohn, in his piece in the Harvard Business Review on incentives in healthcare, wrote, “Punishment and rewards are actually two sides of the same coin. Both have a punitive effect because they are manipulative.”

At QURE, we know that the key is measurement, feedback and pairing incentives with an educational approach that targets changes in clinical practice behavior. In 2011, Mckinsey & Company conducted a physician survey on the topic of changing behavior. Providers were asked to provide the motivating factors that would influence their behavior. Although compensation was ranked the highest, providers ranked training, resources, leadership support of behavior change, feedback on performance, and communication as the other top influences.

The best solution requires a combination of the right measures, incentives (payment and recognition), and education. The failure of the Premier project and comparative success of the Medicare Physician Group Practice Demonstration shows that timely feedback of performance is a critical factor in the success behavior change. To make change sustainable, not only is quality measurement absolutely necessary, but feedback, education and training should be ongoing priorities. In doing so, hospital and practice leadership will be giving their providers incentives to succeed in the fast evolving world of alternative – and potentially worrisome – new payment methods.

From all of us at QURE, we wish you a very Happy New Year!  Stay in contact with us and visit our website or follow us on Twitter/LinkedIn to learn more about our quality measurement, feedback, and education efforts with our many partners.

[1] http://www.hhs.gov/news/press/2014pres/12/20141202a.html

[2] http://www.modernhealthcare.com/article/20141206/MAGAZINE/312069987

[3] Pronovost P, Jha AK. Did hospital engagement networks actually improve care? N Engl J Med. 2014 Aug 21;371(8):691-3. doi: 10.1056/NEJMp1405800

[4] Cassel CK, Conway PH, Delbanco SF, Jha AK, Saunders RS, Lee TH. Getting more performance from performance measurement. N Engl J Med. 2014 Dec 4;371(23):2145-7.

 

[5]http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf406195/subassets/rwjf406195_1

[6] http://www.modernhealthcare.com/article/20140826/NEWS/308269936

[7] Iglehart, J.K., Assessing an ACO Prototype – Medicare’s Physician Group Practice Demonstration, The New England Journal of Medicine, December 2010.

For New Life Science Products, Physician Behavior and Clinical Utility May Be the Great Overlooked Variable

Companies bringing new health care products to the market are very focused on variables that affect clinical validity. Does well the new diagnostic test or intervention perform? How do the specifications compare to existing products? Do we have the clinical data to win clearance or approval? These questions are essential to a safe and successful product launch.

However, one additional and crucial variable is often lost on companies – physician behavior. Developing an effective new diagnostic test is one thing, showing payers that physicians will use it in a way that improves quality and/or reduces costs is a very different and increasingly indispensable part of securing coverage and reimbursement.

Clinical utility – defined as the usefulness of a test in clinical practice – is distinct from clinical validity, but no less important. In fact, failing to demonstrate clinical utility may be the biggest single business risk we see for promising diagnostic companies. A new product that clears FDA hurdles but cannot secure coverage and reimbursement is no closer to impacting patient care or delivering a return on investment.

This fall, QURE published a piece in the American Journal of Managed Care entitled, “New Thinking on Clinical Utility: Hard Lessons for Molecular Diagnostics” (you can access the paper here and a detailed press release here). The piece highlights five basic requirements to successfully gathering clinical utility data in support of coverage and reimbursement:

  • Understand that outcomes are hard to capture, but clinical behavioral change is almost always proximate to outcomes change.
  • Start clinical utility studies early
  • Learn from successes and failure
  • Determine clinical utility with rigorous science
  • Involve payers and providers from the start

It also highlights case examples of promising new diagnostic tests that secured positive coverage decisions with strong clinical utility data (eg, Crescendo Biosciences rheumatoid arthritis test) or failed to win payment due to a lack of evidence of clinical utility (eg, Life Technology lung surgery mortality risk test).

QURE’s Clinical Performance and Value (CPV®) vignette approach is uniquely positioned to quantify the impact of a new product on physician behavior and document clinical utility. If you are looking to generate high quality CU data, give us a few minutes to tell you how we can help.

 

 

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