News

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.

 

 

AJMC Covers QURE’s Work with Hospitals and Life Science Companies

QURE’s work with hospitals around pathway adherence and strategic efforts with life science companies around coverage reimbursement has gotten the attention of the American Journal of Managed Care. Check out the two newest articles released by AJMC in these two articles:

Dr. Peabody Invited to Participate in Autism Speaks Meeting on Screening and Diagnosis in Low Resource Settings

In mid-October, Dr. Peabody was invited as a key panelist for an annual Autism Speaks Meeting on Screening and Diagnosis in Low Resource Settings. The objectives of the meeting included:

  • To better understand the state of the science on screening and diagnostic approaches for autism spectrum disorder
  • To review the global experience with existing and potentially new instruments for screening and diagnosis for the detection and assessment of autism spectrum disorder
  • To identify opportunities and barriers to developing these tools for use in the public domain tool that can advance autism research and enhance services worldwide
  • To consult on the processes for developing new and/or adapting existing instruments, including psychometric and pilot testing, the administration, financial feasibility and eventual widespread implementation of proposed instruments in diverse settings
  • To create a plan with next steps on development of this broad-based initiative

autism speaks

 

QURE at ASCO Quality 2014

QURE and Moffitt are excited to be presenting two more abstracts this year at ASCO Quality. Stop by after our presentations and learn more about our projects around measuring quality and forming a network.

Link to Abstract 1: http://abstracts.asco.org/152/AbstView_152_137647.html

Link to Abstract 2: http://abstracts.asco.org/152/AbstView_152_137666.html

photo (4)

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.

On our Life Sciences Radar: New FDA Proposed Regulation of Laboratory Developed Tests

The U.S. Food and Drug Administration (FDA) recently issued notice that it intends to begin regulating laboratory developed tests (LDTs). While the draft guidance indicates that the new FDA oversight will be risk-based and phased-in over a number of years, this represents a significant change in policy. Even though diagnostic testing systems and kits sold to hospitals and other providers have long required FDA review, LDTs offered by single laboratories have, instead, been regulated by Centers for Medicare and Medicaid Services (CMS) under the Clinical Laboratory Improvement Amendments (CLIA). As LDTs are becoming more sophisticated, it has become clear that LDTs are increasingly used in clinical decision-making, especially in the context of personalized medicine (e.g. genetic testing). This expanding clinical role means that the risk of incorrect or missed diagnoses is a substantive issue, leading the FDA to now impose review of both the analytical and clinical validity of these tests.

Implications for Life Science Companies

CMS and commercial payers are increasingly requesting clinical utility evidence as they consider coverage decisions for diagnostic tests. New FDA life science regulations, therefore, should not be surprising. QURE sees this new intent to regulate as a way for the FDA to eventually align regulatory requirements with the needs of payers. The proposed regulation will significantly impact commercialization strategies for LDTs, especially for those tests deemed highest risk by the FDA and thus subject to the greatest level of oversight. We see this as the first step towards aligning LDT approval with eventual requirements to secure coverage and reimbursement. Eventually, successful LDT commercialization will require studies and data confirming not only performance and good manufacturing practice but also clinical validity and utility. As the FDA begins down this regulatory road and payers expand their focus on value demonstration, strong supporting data will be key. This will lead to higher, evidence-based barriers to entry and give life science companies that are already generating this data, or making concrete plans to do so, a significant competitive advantage.

QURE Recently Published in International Journal for Quality in Healthcare

Check out QURE’s recent paper that was recently published in the International Journal for Quality in Healthcare on one of our projects in Kenya and Ghana!
The objective of the project was to measure level and variation of healthcare quality provided by different types of healthcare facilities in Ghana and Kenya and which factors (including levels of government engagement with small private providers) are associated with improved quality.
The full article can be accessed here.

Dr. John Peabody Delivers Presentation for First Annual Moffitt Pathology Symposium

Dr. John Peabody delivered one of the keynote presentations at the First Annual Pathology Symposium at the Moffitt Cancer Center. The symposium focused on current challenges in pathology and Dr. Peabody’s presentation provided an overview of emerging technologies and health/payment reform measures that will impact the practice of pathology.

Additional information on the Symposium can be found here.

Dr. John Peabody Gives Annual Patt Lecture at LVHN

This week, Dr. John Peabody gave the annual Patt Lecture at Lehigh Valley Health Network. Dedicated to discussing updates in cancer care, this year’s Patt lecture was intended to give a contextual background on healthcare reform in the United States and how this is affecting cancer care directly. The talk covered the current costs of healthcare today, health care reform, consequences of reform and strategies for improving quality and lowering costs.

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