PLEASE NOTE: This is an unedited transcript. Please refer to the video to confirm exact quotes.
SARAH DASH: Alright, good afternoon everybody. Thank you so much for joining us today. I am Sarah Dash, I’m president and CEO of the Alliance for Health Policy, and for those who may not be familiar with us, we are a non-partisan organization dedicated to advancing knowledge and understanding health policy issues. We are delighted that you are here. Hello as well to those who might not be in the room, but might be following us on Twitter at Allhealthlive.
We are here today to examine quality measurement for people with complex care needs, and the important implications of quality measurement for related work on policy issues such as Medicare, Medicaid, and delivery system reform. Our goal is to better understand the essential attributes of person-centered care, and how to translate these into quality measurement and real-time practice. Before we begin, I would like to thank the SCAN Foundation for making this briefing possible, as well as to the Valerie Wilbur Health Policy Fellowship Fund for additional support. We are really lucky to have an excellent panel here with us today, and I’m going to go ahead and introduce our panelists now.
All the way to my right, to your left; RoAnne Chaney is Executive Director of the Michigan Disability Rights Coalition. Her expertise is in long-term care, community and agnation and meaningful consumer involvement. The patient perspective is important to everything we do here at the Alliance, but it’s particularly critical for today’s discussion on person-centered care. So, thank you, RoAnne for being here.
Next, Bruce Chernof is the President and Chief Executive Officer of the SCAN Foundation whose mission is to advance a coordinated and easily navigated system of high quality services for older adults that preserve dignity and independence.
Immediately to my right, Erin Giovannetti is Senior Research Scientist at the National Committee for Quality Assurance, NCQA. Her work focuses on developing healthcare performance measures for older adults and for vulnerable populations.
John Bernot is Senior Director of Quality Measurement at the National Quality Forum. Dr. Bernot is also a part time practicing family physician at Wake Forest Baptist Peace Haven Family Medicine Clinic in Winston-Salem. I almost got it out. Thank you for joining us.
Finally, Nelly Ganesan, is a Senior Director at Avalere, where she advises clients on the implications of quality related healthcare policies, including public and private quality reporting programs, value based care, and payment and delivery models.
We are going to go ahead and start with Bruce Chernof.
BRUCE CHERNOF: Terrific. Good afternoon, everybody, it’s really a pleasure to see all of you today. For those of you who are watching on the screen, our room is full, which we just see as an incredibly positive sign about the value and importance of quality measurement. Let me just say quickly that the SCAN Foundation fundamentally believes that all older people should live with dignity, choice, and independence. All of those with functional limitations should live the same way.
Our discussion today is really about, where does quality go to help measure that beyond the way we measure today? The Foundation has focused on developing what we consider a set of essential attributes for measuring quality from a person’s perspective. And that was developed through a consensus process, and I really want to acknowledge all of the folks on the screen, and their organizations who came together to wrestle with the tough issue of how do you think about quality from a person’s perspective, and how do we begin to do that in a way that can be measured? And the systems can be held accountable in the long run for the person’s perspective, not just for the technical quality of care.
When we look at the essential attributes, there are really four. These are meant to really compliment the technical quality measures, which we have today, and continue to develop and refine. So, the idea that we build a plan of care that is based on people’s needs and goals, that those needs and goals are incorporated in the compassionate way into that plan of care, and that there is a cohesive and easily navigable system that actually can work with the individual, their circle of care givers, their family, to achieve that plan of care, and that ultimately, that the plan is revisited on a regular basis. It is informed by experience, and that it’s kind of a virtuous cycle. That experience drives the next generation of quality as people’s needs are addressed and met. Ultimately, this is hard. We live in an environment where funding in healthcare. Not the other way around. And so, how we measure quality and then how quality is tied to how we evaluate systems, how we set minimum bars, do you meet the requirements to be a contracted provider or to be a part of this program? And how we set maximum bars. How we acknowledge outside success. These are difficult questions. But these essential attributes and the work of the group that came together to develop them, I think, is a great foundation.
I want to just thank the Alliance for Health Reform for this event, but also all of your leadership in this space.
SARAH DASH: Thank you. Next, we will turn to RoAnne Chaney to talk about person-centered accountable health. Thank you, RoAnne.
ROANNE CHANEY: Thank you. I wanted to start by just giving a little bit of history of what I would call a personal, planning and process. In Michigan, we established person-centered planning in our mental health code statute in the ‘80s, that applied to both people with developmental disabilities, and people with mental illness. We followed that in the early 2000s by applying and requiring person-centered planning to be used in our aging and disability waiver for home and community-based services. Most recently, Michigan has a dual demonstration under the Affordable Care Act, integrating Medicare and Medicare payment. And when we established that, advocates demanded in Michigan that that process include person-centered planning. So, the first-time person-centered planning went from not just a home and community based services process, but something that also applies in general health. There was a lot of argument about that, but it has happened, and I will tell you in a minute or so, some examples of its positive impact.
There are a lot of different definitions, CMS has one, state of Michigan has one, I’m sure there are other ones out there that have been used in European countries and other states. But there are common themes that I’ve listed on this slide. And there are two that I forgot to put on there that I want to emphasize. One is the whole process; presume a person’s competence, unless there is hard evidence that competence is not there. I know all of you may be aware that people with disabilities and often aging people, are sometimes perceived to not have competence, when clearly, they are very competent. So, that is part of why that’s in our code. And the other one is that behavior issues should first be interpreted as a form of communication. Often people who are non-verbal, whether they have dementia or they have a developmental disability or a physical disability that prevents them from communicating like you and I do, verbally. Sometimes they, in order to get people’s attention, or communicate that they don’t like something, they have to use extreme means to get people to see that, and I have a lot of examples of that, that I don’t have time to present. But they exist.
It’s also a process that we say, you have to look beyond purely clinical issues of your physical and mental well-being, and look at a person’s environment. So, you get to the social determinants of health, and analyzing what is going on in a person’s life. I use one example for myself, when person-centered planning was not in process, and people were not looking at me as a competent person to access my own abilities. A few years ago, I did something really stupid and fell out of my wheelchair and broke both of my legs. At the time, I was absolutely independent, lived my own life, lived by myself. Did use assistance. But breaking my legs severely impacted that ability. So, I was told by all of the clinical folks in the hospital, I needed to go to an extended care facility. I said, no, I don’t, I know how to manage. I know lots of people who do manage, I can figure this out. They did not give me credibility on that. And it wasn’t until I called a social worker colleague that I worked with at the rehab unit of that hospital I was in, and she came in and wrote in my chart that I was the Associate Director of a Center for Independent Living and I knew how to do this. Then she expressed to me in my room: I shouldn’t have to do this. And she kind of swore and said: I have a lot to do, I shouldn’t have to take my day, but I did it. And that’s when I got credibility, and I said, yeah, you are right, you shouldn’t have to do this, I shouldn’t have had to call you. But that’s how I got credibility, is because I had a relationship with a professional in the system. What about all of the other people that are not given credibility, that should be.
That’s the negative. You can always see it. It is very — I will get to that part. It’s hard to measure, but you know when it’s present, when it’s not. As we’ve moved into practicing this in primary care, through the health plans and the demonstration in Michigan, one of the medical directors was telling me about a situation they had with an older woman who had inadvertently gotten her home delivered meals cancelled. It was an error. But she had called them when she had no food in her house, and they got this woman some food for the weekend, it was a Friday, of course. And he said to me: I was very concerned about this woman taking her medication, her diabetes medication, and all of these other medications she was on, at the right time and the right dosage. He said, how can she do that when she has no food in the house? How can she focus on the right medications when she has no food in the house? And I thought, oh, the medical system is getting it. They’ve got to look beyond the person’s body, and look at what’s going on in their life.
So, that is very difficult to measure, and how do we do that? I have amassed a lot of anecdotes of when a person’s received person-centered services, care, whatever we want to call it. And there is a former director of our behavior health system in Michigan that says, yeah, I have a lot of anecdotes. Lots of anecdotes of this system working and this process working. He said, like you, I always get dismissed, because they are anecdotes. And he said to me, and I love this quote: How many anecdotes make data an evidence? How many do we have to have? Some people are concerned that if we establish minimum sets, you are not really getting at the process, the whole process, and doing it right and really understanding what’s going on with individuals. So, I think it is a challenge. We have been challenged by it in Michigan. There is now a person that is going devote more time to find out, how do we make sure this system is doing this? It’s important to do, but we haven’t hit on the right formula yet.
Doing authentic person-centered planning — and there is an article in your packet — very important to healthcare. It’s a process that could be transformative to the person and also gives staff a really rewarding experience, when it works well. And is it cost effective? We believe it is, but we don’t have a lot of data about that.
So, thank you.
SARAH DASH: Thank you. RoAnne, if I could ask you a quick follow-up question before we move to Erin’s presentation. Thank you so much for your presentation. You mentioned this as part of Michigan’s code now in terms of the requirement to do person-centered planning; who is actually responsible for making sure that that happens?
ROANNE CHANEY: Yeah, it’s a good question, because our state did contract exclusively with our county community mental health boards, and that responsibility was contracted to them. Now they are going to another — they’ve been moving to another managed care system, they are talking about integrating behavioral health with physical health and that’s one of the big questions, is who’s going to be responsible for this? But it’s one that advocates are united on — somebody has to be. Yeah. It’s not totally known. Right now, ultimately, it — because it’s in code, everybody is. And particularly the mental health system.
AUDIENCE MEMBER: [inaudible]
ROANNE CHANEY: I have qualified faith, yes. I have seen a good — being a person that was involved in training our new integrative care systems, I have seen at the care coordination level, which is when I think is really important, to make sure it happens. I have seen a lot of good reception to it.
SARAH DASH: Thank you so much. The question of kind of, how we take what’s important to people, how we measure it, and then how we — John and Nelly are going to talk a little more about how we actually translate that into real life and what accountability for all of that really means. So, thank you for shedding light on that for us. We will get to — after the presentations — an audience Q&A. As you are thinking of questions, I will just quickly mention it now, we have green cards on the table, so feel free to jot questions down as you are thinking. Thank you. Next, we will move to Erin Giovannetti. Thanks, Erin.
ERIN GIOVANNETTI: Thanks. Thank you all for inviting me to speak here, and for you guys, for attending during your lunchbreak, to listen to us talk about this. I’m going to talk about how we actually would measure whether or not that — you know, the person-centered care that RoAnne was speaking about, and the attributes that Bruce was speaking about, how do we actually “rubber hits the road” measure whether or not those are being implemented? I’m going to talk about a project where that’s been funded by the SCAN Foundation and The Hartford Foundation.
In quality measurement, the way we tend to do things, is we pick a population and we measure something. We measure the same thing across an entire population. And the challenge with this, when you think about a complex population, is that you are really dealing with a very heterogeneous population. And measuring the same thing in every person may not get you to the point of measuring what matters most. So, we actually, under this grant, went out and we talked to people. We did focus groups across the country, and this is just focused on older adults that have a level of disability, but I think this could apply to any population. We asked them, what matters most to you? What do you want to get out of healthcare? Some people talked about health and quality of life goals; they talked about managing symptoms, stop falling as much, increase mobility. They talked about values that were important to them, like having privacy, choosing who cares for me in my home. They talked about care preferences. Not so much about the outcomes, but how they wanted their care to be delivered. I want to stay out of the hospital. I want to get my doctors to talk to each other. And they also talked about goals they may have for their family and friend’s caregivers that are helping them. I want to help my caregiver to be less burdened. So, when you think about all of these things, we would not want to develop one measure for each one of these things that’s up there, because we know that there are already too many measures, and that not all of these things are going to be important in front of everybody. So, how we do develop a system that actually measures these individualized outcomes?
This brings us to person-driven outcomes, which is what I’m going to be talking to you about, which I feel are measuring both attribute one, and attribute two, from the essential attributes. And they are essentially individualized outcomes, identified by the patient or the caregiver as important. So, it’s what they are telling you, is what’s most important to me right now at this given time. I think a really important thing about these outcomes, is we want them to be useful not just for quality measurement. We don’t want them to be just things you are doing for quality measurement, but actually outcomes that are informative for care planning. Something that are using this information as helping you to provide better care.
We developed a process for actually collecting person-driven outcomes. It starts by eliciting what’s most important to someone. So, I started off before this project, doing a lot of work, looking across different records, and all of these organizations said: We do goals. We do person-centered goals. Everybody says: We do person-centered goals. And when you look at what the actual person-centered goals are that are documented, there are good goals, and there are some bad goals. There are some organizations where goals are autogenerated from a risk assessment, and it autogenerates, well, your goal is to get your hemoglobin A1C under control. They are not actually person-centered goals. And so, we need to really understand the process to how do you get to goals that are truly what someone wants? So, we developed a goal inventory, and I’m sure this is probably too small for you to read, but using that input from the focus group, we developed these goals that is a discussion tool that you can use between an individual and the clinician that is working with them, to say, what is most important to you right now? Is it around your healthcare? Is it around your physical activity? Is it around choice and control? Is it around things in your community?
Once you have a goal, we need to know, how are we going to measure whether or not you are achieving this goal? So, we did two different methods for that. The first method is called “goal attainment scaling”. This is not something new, we didn’t invent this. This has actually been used pretty extensively in rehabilitation medicine, where you lay out a goal along a scale of what you would expect your outcome is, what you want to get to. So, for this individual, the expected outcome is to resume driving in six weeks and fly to California to visit family for the holiday. That was their goal. Then you lay out what it would be like to do even better than that goal. So, what would it be like to do better than you expected? So, to resume driving in four weeks, and fly to California in time for Thanksgiving. What would it look like to be less than expected? To have complications from surgery, and to not drive for at least three months, and not make it to California for the holidays. Once you’ve laid this out along the scale, the actual process of discussing this with somebody and helping them to talk through what it means to actually meet this goal, gives you a measurable scale that you can use to look at goal achievement.
This works for some people when they’ve got a very specific goal. When they know exactly what they want. Some people don’t always have a very specific goal. They have something like, I want to be in less pain. I want to feel happier. So, here is where we have another method which we call “prioritized person reported outcome measures”, just because we like to throw a lot of words into our definitions. Here, we took all of those goals that we had in our goal inventory, and we matched them to where there are existing standardized tools for measuring those outcomes. So, when you think about the goals around depression, anxiety, sleep, pain, there are standardized tools for measuring those things. We put them in a bank. Now, if we were to ask somebody all of these questions, you have about a 300-item survey that no one is going to fill out. So, instead of asking a 300-item survey, we say, well, why don’t you just match the PROM, or the personal reported outcome measure, with the individual? So, here, you have two individuals: Mr. T, his goal is he’s just got too many medications, he can’t keep track of them all. Everything is just really difficult. He wants — he’s going to use a healthcare task difficulty scale, that’s going to measure how much difficulty is he having with his healthcare tasks, and he wants that to decrease. Mrs. S, what she really wants is she really wants to be able to get more of the services and supports in her community. She needs to get connected to community resources. We are going to use and access to services and supports scale for her. Now, each individual has a different scale that they are using, a different questionnaire. But at the population level, we can know whether or not the population is achieving their goals of either improvement or maintain on that particular person reported outcome measure.
I know this sounds really complicated, like, how would you actually get clinicians to do this? Which is the first thing I thought when we were coming up with this. Like, this is all great in theory, but come on, we’ve got a five-minute doctor’s visit, no way this is going to fit in. So, we did this in seven different organizations and we got them to implement this, and this is some of what we actually came out of the data: So, these are the types of outcomes that we saw. When they actually sat down with someone and prioritized, what is the thing you want to work on most in the next three months, we see these outcomes that are all over the place, from healthcare utilization to physical, psycho-social, independence, travel and vacation, caregiver goals. They are really all over the place. In the 186 patients we had in this, we actually followed — well, how many achieved their goal? So, the first thing we wanted to know was, how are you actually doing on following up on the goal? What we saw was that across both the methods, the goals attainment scale, the PROM, that 87% of people had a follow-up on their goal, which is actually really good in terms of engagement. About 60% achieved the goal. Here is just a quotation from one of our participants: “You know, you can tell somebody what to do, but I think you convey better things when you give people options to do it, find out what they like.”
One thing I will note about this, is that 60% of people met their goal, but when we talk to people who didn’t meet their goal, they weren’t dissatisfied with their care. In fact, when they talked about this, they felt that not meeting their goal was actually really informative to them, about what they could do to help meet their goal in the future. So, this process is really the thing that engaged people in their care.
I will just close with a couple different quotations from the people that we’ve engaged with this. One from a pilot participant: “I found in doing some of these things that we put down, there is a strength in me. People were far more engaged in their care when they were doing this.” Then from one of our nurse case managers: “All of a sudden, they were totally engaged in healthcare and that was new for a lot of them.” I thought that was really cool.
SARAH DASH: Thank you so much, Erin, and this brings to mind a little bit of a follow-up question. We hear a lot about patient engagement and patient satisfaction. Interestingly, it sounds like from what you are saying, when you engage the patient, the people more in their care, they are far more satisfied with their care. Is that fair to say?
ERIN GIOVANNETTI: Definitely. I think that for a lot of these people, engaging them in these very specific, detailed conversations about their goals, did engage them more in their healthcare and made them more satisfied with the care that they were getting from their care manager.
SARAH DASH: If I could ask one other clarifying question, you mentioned the seven organizations: Can you say something about the types of organizations that you worked with?
ERIN GIOVANNETTI: So, we had three health plan complex case management programs, two home-based primary care programs, one patient-centered medical home — have I gotten to seven yet? There was another complex care management program in there.
SARAH DASH: Great. We will now turn to Dr. John Bernot from the National Quality Forum.
JOHN BERNOT: Well, good afternoon everyone and thanks again for having me. I really want to thank both the Alliance and the SCAN Foundation. We’ve had the privilege to work with the SCAN Foundation and some of what I’m going to talk to you about is taking those ideas and work that we’ve done. I’m going to start with: How do you build measures or set a foundation to build measures around the patient voice? So, a lot of what Erin has already said, it’s going to converge into the same themes that we have, but we are really trying to set a platform that is something that we can use to help facilitate measurement in this field.
I will start just with our very generic — this goes along with Erin’s, but for us, a patient reported outcome is when a patient gives some report of their health status to us that is not interpreted by a physician or anyone else. So, they are actually telling us something about their health status. That information, and we heard a little bit about anecdotes, it gives us the ability to start taking these anecdotes and making these responses into data points.
So, we begin to move into the measurement field in a very systematic way there. And then the measures, they are just quantifications of these responses. One of the ways that we’ve been trying to facilitate that is, we have a group called the NQF measure incubator. And what we are doing in there, is we conduct strategy sessions and look for meaningful ways to bring the patient voice out in the field of measurement. We try to do this very early on, before the measures are already baked, so that we have the right people around the table. These are multi-stakeholder, multiple perspectives — patients, hospitals, clinicians, that are sitting around and getting input onto these measures before they are made, so that they can come out with the best — the best success at the end.
We’ve done this over some really prolific topics. Chronic obstructive pulmonary disease, which you know as COPD. Rheumatoid arthritis. Multiple scleroses. I would suspect, if you took a moment, you know a family member or a friend that has one of these. These are chronic diseases. They are real, and they affect lives for not just a day or two, but for years and year and years. So, the goal of what we are looking for, is to facilitate, how do we measure this, and how do we get to the point where we incorporate the patient’s voice? The patient wants to live the life the patient wants to live, and that’s extremely important to us. And we want to make sure that’s being heard. In fact, as a clinician, it’s almost — it takes me back a little bit that some of the things that we do sometimes actually impedes the livelihood of a patient, because we are following the care plan and not listening to what the patient’s priorities are. So, these measures help us get to that point.
I will give you an example of this in action: We did a recent project with the Robert Wood Johnson Foundation, and patients like me, where we got very, very early input from patients as to what was important to them, when they are being treated by their physicians. Unlike what we are always taught in medical school, and what we are currently measuring, which is what’s the longevity, how do I prolong life, or even to manage pain. That was not it. It was, can you help me with my fatigue? I want to do my daily life. I want to be involved in the community and you need to help find a way to track that. Simply put, the patients are sick and tired of being tired, and that’s what we need to focus on as physicians. I definitely take this to heart to try to make sure we are incorporating this. Are we doing anything that is going to take them away from their goals here? This really sets up well for a place where we can get patient reported outcomes and get patients involved in the quality of their care. That’s on the measurement side of what we’ve done there.
Beyond measurement, we do work with our members. We are a membership organization, we have a lot of different members across the healthcare spectrum, and they help us out by coming to the table for these things and one of the things we’ve had them do is actually sit down and help us make practical actionable guides — playbooks for clinicians or for healthcare organizations. One such thing is, we have an action brief on shared decision making. In this brief, it actually gives guidance to a clinician as to, how do you facilitate those conversations? These are not easy, and if you’ve been part of that, which I suspect you have, you know these are sensitive discussions already around the patients’ livelihood. Trying to preserve the dignity and trying to remain patient centered can be difficult, especially the ways some of us have been trained historically. So, it gives us a chance to reflect, it gives us some guidelines, some discussion points. It helps us frame our encounters with our patients and making sure, again, what that patient wants is at the center, and that we are very careful to make sure that our clinical decisions don’t affect their livelihood in a negative way.
The action brief, which is actually included in your packet, in the full length — if you look, it relates right back to these measures that we talked about with the work with the Robert Wood Johnson Foundation. Those things that we are learning from the patients, are the things that we are trying to work into a guide and work into this combination of both measurement and guidance here.
So, I’m trying to be sensitive to time, but in closing, I do want to say, there are a lot of great projects in this area. And as you hear, we are all working towards really, really the right goals. It’s an immature field that is growing right now, and that is why we are all here today. But I mean, I really believe, collectively, as a community, this work is what’s going to ensure that the patient’s voice is heard and incorporated into these decisions.
So, thank you.
SARAH DASH: Thank you, John. If I could just ask: It seems like really trying to incorporate the person’s voice into the — what is measured in terms of quality, it really seems to represent kind of a C change in how we think about what quality of care really is. I wonder if you could comment on that. Also, as a practicing physician, if you could talk about how does that change, or how might it change the way that health care is practiced? We hear a lot about the concerns about too much quality measurement, too much burden. Can you speak to that a little bit in terms of what this change might mean for daily clinical practice?
JOHN BERNOT: Absolutely. And I will start by saying, I completely acknowledge, and your question is spot on. I mentioned we are immature in this field, and by immature, I mean that we are really good at measuring processes and things that are done, that technical medicine, we are good at. But trying to incorporate this, is something that we are still not there yet, and I do think we are in a learning phase of how to incorporate this, and on the provider side of this, it’s going to be difficult for some individuals, I believe, until this begins to fit within the care we deliver. For example, if it becomes yet another thing, another box to check while still being — checking the boxes for the technical medicine, this could be something that could add burden. So, I think the best way is going to be whenever we can incorporate this into the way that we assess clinicians, both in terms of their performance and potentially even so far, at some point, into the way that performance-based payment models are done. I don’t think we are quite ready, but I think if we can integrate it into our daily work flow, it will be the best chance of us getting success on the front lines.
SARAH DASH: Thank you so much. We will now move on to the final presentation for this panel. We hear a lot about, not only quality of care, but also value based care and the move from volume to value, or from fee-for-service to value-based care. It’s become sort of a mantra. But here to help us better answer the question of what value-based care really means from a person perspective, we have Nelly Ganesan from Avalere. Thanks.
NELLY GANESAN: I want to thank SCAN and the Alliance for having us, I think this is a great discussion. I get excited when I see this many people who are maybe interested in quality measurement and patient reported outcomes and how we think about value-based care, so hopefully you will find this discussion helpful.
I’m going to try to talk a little bit about also sort of how the different aspects that we’ve talked about, align with the policy environment. I think that that’s where a majority of you are coming from. So, hopefully some of these terms that I will use will make sense to you.
Really quickly — I’m just going to talk at a very high level as to what Avalere Health is. It doesn’t come off from the name of the organization as to what they may do. Also, it will help shape some of the comments that I’m making as well. We are an advisory services organization, sort of focused on policy as well as implementation. Although I will be talking a little bit about person-centered care and measurement and value-based care today, that’s just one aspect of what the organization does. We also focus on helping a variety of our clients that include health plans and physician groups, pharmaceutical manufacturers and medical device companies, sort of prepare for different changes as it relates to healthcare. So, a lot of aspects of policy and legislation that you may be tracking, we are doing the same thing and thinking about sort of what the long-term payment impact or also how an organization would change kind of their internal strategy as it relates to what’s happening externally. That’s what we spend a lot of our time doing, and I think one thing that I will say before I get started, is we are talking a lot about person-centered accountable care today and a lot of my remarks will kind of be linked back to the kind of quality measure environment, which all of us are linked to. I think that is a piece that sort of falls within all the different pieces of legislation and all the different policy pieces that folks are tracking — everything from, you know, if we look at sort of how the exchanges are — how folks are enrolled in the exchanges, as we think about Medicare Advantage and as we think about how people start to kind of choose their plans, a lot of that comes down to quality, historically, as these folks have mentioned. We’ve focused on this idea of process measures, and there has been a lot of ask to move towards outcome measures, but measuring those types of things isn’t always so easy. So, then if we take outcome measures and funnel it down to patient reported — or patient-centered outcomes, there are a lot of challenges there, and collecting that data as well.
I’m just going to take a couple steps back for folks that sort of maybe want to get a grassroots understanding of sort of why quality is important. I know we’ve talked a little bit about that here, but in 2015, Health and Human Services had set out goals to basically say that they wanted to have these goals to mitigate fee-for-service payments with what’s happening in the value based world. At that time, the goal wasn’t fully defined in terms of what meeting that goal would look like. HHS had noted in 2016 that those goals had been met, but maybe the definition of how they were sort of thinking about alternative payment models and what was being captured in those alternative payment models, wasn’t exactly what they were looking for. So, for those you that are sort of tracking everything that is happening on the macro side, and advanced alternative payment models, you know that there has been a lot of new models that have been added that have sort of more upside risk, and so I think HHS is still moving towards achieving those goals, and you still have a lot of clinicians that are aiming to enroll in those programs, and that’s when we start to think about sort of the idea of quality measures in those programs and what clinicians can do to meet those quality measures.
Taking that same piece, the other thing — I know we heard earlier that the definition of person-centered care sort of means different things to different people, and I think the idea of value and quality also really means different things to different people as well. So, on this slide, we have patients and providers and payers, and life science companies. I think overarching what it means to everybody, is this idea of getting the right care at the right time across the different spectrum. What we’ve noticed, is sort of in the development of quality measures, where we started out with process measures, in some cases, efficiency and structure measures, and moved a little bit towards outcome measures. That idea of measuring sort of what is most important to the patient, I think, is relevant for all of these different stakeholders. But maybe how they look at measuring those pieces of care, isn’t always aligned.
I’m going to skip over this slide and focus towards the end here. This kind of goes back to a little bit, providing examples of what we meant by what was historically noted as the measures that we had, that maybe didn’t necessarily look at person-centered accountable care. So, things like whether a patient received an immunization. Whether they were enrolled in smoking cessation program, whether they got their A1C checked. I think what’s interesting is, this article was published in 2013, not that that was that long ago, but these same sorts of pieces on the right-hand side of what future measures would look like. So, addressing things like patient harm, and addressing things like patient-centered care, and a variety of patient reported outcomes that measure things like functional status and quality of life, and patient experience, are still very questionable in terms of the work that’s being done to measure them. I know we have heard some great work in terms of modes and advances to get to those different pieces of data collection, but I think that there are still some optimal challenges to do that.
The one thing I wanted to introduce and maybe spend a little bit of time here, is there is a lot of work that is happening with the Centers for Medicare and Medicaid Innovation in terms of re-thinking about how they really capture aspects of patient-centered care. There was a recent request for information that was released, where they are doing a redesign of what they are looking at, in terms of how those models would be rolled out. One of the key things that was noted, is that they are re-evaluating all of the models that they have, so that they actually address something like patient-centered care, and they provided a very — I don’t want to say a concrete definition, but a good definition on empowering patients and families to take ownership of their health, and to ensure that patients have the flexibility to make these informed decisions. One piece about doing that, is when you think about these models, they all have some element of quality measurement that needs to be included. So, taking the work that’s been discussed here, and really advancing and growing those types of measures are kind of one of the only ways that a model like this can move forward. So, I think with the contributions of various stakeholders and different consensus building, a model like this can be rolled out, as long as there are those measures that exist that can be included.
Just to wrap up, I think we’ve talked a lot about this, so I don’t want to re-focus on this, but the idea of having these patient-centered measures, I think, is not just a benefit to patients, it’s a benefit to a variety of different stakeholders. Oftentimes in these discussions, one of the sort of key stakeholder groups that gets left out, is sort of that idea of the caregiver, and I think that that’s an important — that’s an important individual to think about when you think about patient-centered measures as well.
SARAH DASH: Thank you so much, Nelly. Let me ask you one technical question, maybe for those who don’t follow these issues quite as closely. You talked about process measures versus outcomes measures. If you could maybe lend a little more color around that, and can you maybe go into a little bit depth about what that means?
NELLY GANESAN: Yeah, and I’m sure these folks on the panel can do it even better than I can, but I will take a stab at it. A process measure is measuring a very sort of standard processes of care. So, I think an example that is oftentimes used, is, did a patient receive a flu vaccination? Or did they get their AIC checked? Just looking at sort of a very snippet in time where an outcome measure technically — and this gets a little bit challenging when you think about sort of all the variety of outcomes there, but a good sort of measure to think about with that, is maybe a re-admissions measure. So, was a patient re-admitted within 30 days of having a specific condition? So, it’s looking at a long-term outcome, versus that process measure, which is looking at a very sort of snippet of time. Maybe John can talk to that too, or —
JOHN BERNOT: No, I think you answered it very well. It’s that snippet in time; did I do a check box, is the process. And some processes are very well linked to outcomes, so it’s not to say that it’s bad, but the outcome is that end result and usually a little bit more complicated as to the measure itself. As to how are we measuring this? And beyond that, without getting too far down. Who is responsible for that one outcome, which may be a group of individuals.
SARAH DASH: We’ve reached the Q&A portion, and some people have already started sending up green cards, which is fantastic. So, this is your chance now, if you have a question, you want to write it on a green card, someone from our staff will come pick it up. You may also wish to ask your question live, and I can’t really see them from where I’m sitting, but there are two mic’s in the aisles there. But let me just — while folks are getting their thoughts organized, let me get it kicked off with this question: What is the fundamental purpose of quality measurement? What is the ultimate goal? Is it the triple aim? Better care, better health at lower cost? Is it related to payment? When we talk about value, oftentimes there is a question of something that you get for your money. What does that mean in terms of how we think about measuring quality?
NELLY GANESAN: I can start to answer that. It sort of addresses some of the aspects that I was intended to cover. The overall value of quality measurement, that is a very philosophical question. I think some people would say that it’s in some cases being a little bit more transparent, about the types of sort of processes that are taking places between — you know, in the purposes of what we are talking about today, between the physician and the patient. In some cases, I think we can say the purpose of quality measurement, especially as we move towards value, tends to be a little bit more linked to accountability. I think a third piece of that is really showcasing performance over time. So, I think a lot of people argue that that is some of the issues with the process measures. You can’t actually start to look at whether you are improving a patient or an individual’s care over time, if you are just measuring a process. And so, that’s why with these discussions around more sort of increased value based purchasing programs, and pay for performance programs, are really starting to look at not just a moment in time, but over a period of time, is a clinician improving sort of the type of care that they are delivering.
SARAH DASH: We have a couple questions here that get into profession specific or specialty specific quality measures. There is a question about how we would advise those who want to develop meaningful quality measures for specialists. And a related question that some professions, like occupational therapy, already have specific evidence-based assessments for certain things like social participation and health task difficulty. The question is kind of: Is there room for these kind of occupation-specific or specialty-specific measures, in the kinds of frameworks that we are talking about? And how does that relate?
ERIN GIOVANNETTI: So, I think yes, there is definitely room for specialty specific measures. I think where we need to aim for, is trying to have alignment, and trying to have specialties work as a team for what the individual needs. When we think about — if I was to take occupational therapy, you know, occupational therapy has their assessments, they look at healthcare tests, how difficult they look, functional status; and those are really great things that they need to know, but they are not the only provider for that individual. That individual has a lot of other things going on. And so, when I think about quality measurement, I tried to think about everything that that individual has going on. What do they want to achieve out of that? And we think we still struggle with, how do we hold individual providers accountable for what is shared accountability for an individual? And everything that is happening to them. I think we still have work to do in terms of figuring out how we have a measurement system that works for individual providers, but also has a higher level of looking at what’s happening for a whole person.
DR. JOHN BERNOT: I can speak to that a little bit from our philosophy and probably already starting to sound like a broken record. But to us, starting this off is really getting the right stakeholders in a room before we go down this path? So, how do we get the perspectives of different individuals in healthcare? I would agree with what Erin has already said: I do think there is room for us to look for more measures in this particular space. We don’t want to explode measures, but this space does need more good measures. I also agree with Erin — when we start looking at outcomes, and some of these things around patients are outcomes, we really do need to look at what level of analysis. Is that a clinician can affect that? Or is it the team, which, as Erin mentioned, if we are looking at teams, that takes the need to have less of these individual specialties, because it may be a team caring for a particular population or a particular condition, and not necessarily the occupational therapist or the orthopedic surgeon. So, I do think we have room for this. I think we would want to have this done in a multi-stakeholder way. Again, I do agree with everything that Erin had mentioned.
BRUCE CHERNOF: I guess I would just add, more as an outsider looking in, but as a physician as well, is that the challenge that I would lay out for those of you who are thinking about this or the specialist question, is it’s ultimately about what the person wants and needs. And I worry a lot about — I completely agree with what the other speakers have said, but I don’t — if all we do is create more specialty measures, we did a better job with that hip, and that tooth and that this and that. I mean, I would just ask all of us to close our eyes for just one second, and say, is that really what’s important to me? And we all want technically good quality care, right? There isn’t anybody on this panel who would disagree with that, and I doubt there is anybody in this room. But it’s also — is this the right decision for me, given the tradeoffs in my life — are we balancing the tools that are available, with the goals that I have? So, I think as we think about who are the stakeholders who are involved in the discussion, and making sure that the voices of people are heard, and that the values that we all keep for ourselves and our families, are on-balance with the technical quality of care. That’s really important. And the last thing, since neither of you — you touched on the team, which I totally agree with, but would push further is — as a physician, I do think we can learn a lot from the medical disciplines that aren’t being a doctor or being a nurse. I think that understanding other disciplines that really do think even more about function outcomes. The rehab specialties and whatnot. I think it would be very powerful. I think there is a lot of learning to be done here on behalf of people and families and patients, when we are patients.
SARAH DASH: There is a bit of a follow-up to that question: Person-centered care, is what all physicians strive to achieve, but there is the question about healthcare professionals who are providing care in the clinical setting, kind of their satisfaction and this challenge of, are we creating too many boxes to check? What the goals are. So, if folks could kind of comment on that and again, Erin as you noted, 15 to 20-minute visits or less, don’t necessarily provide enough time for these kinds of person-centered assessments. In the real world, how does this play out?
ERIN GIOVANNETTI: I can say, on our project that we did, we had of the seven sites, two of the sites had physicians doing this, and the rest had a care management team — either nurses or social workers. One place even did it with community health workers. It worked far better when they had a team doing this, then when it was the physician alone responsible for it. I apologize to the physicians on the panel and to those in the room — they were not very good at this. They looked at people and said, I know what your problem is, I can solve it. As opposed to sitting there and asking people what they wanted. So, when I think about how this is going to actually roll out, it is about a team and it is about having that support network of nurses, social workers, and other disciplines that can help to support a full team, that includes the medical perspective, as well as non-medical perspectives, in terms of helping people to achieve these outcomes.
SARAH DASH: Of course, measuring quality is important, but what about cost? Does this necessarily mean, measuring this kind of quality in the way that we are talking about it, does it necessarily mean it costs more? Can you get to addressing that question?
ERIN GIOVANNETTI: So, who is going to pay for it? In the places that we were working in, these were — how was it paid for? It was either health plans or other accountable entities that were at risk and wanted to find ways in the end to reduce high cost utilization. Reduce hospitalization, reduce emergency department visits, and reduce placement in nursing homes. We have not gotten to the point of proving that this is going to improve those outcomes, that’s our next phase. But I can tell you that when I talk to people that were engaged in this, what they said was, “I’m getting people to engage in discussions about their health in a way that I was not able to before.” In the end, if you want somebody to take care of their diabetes, and to take their medication for their diabetes and what they are saying to you is, “I can’t take my medication for my diabetes, because I need to be putting all my money into my medical care for my cat right now, because my cat is the most important thing in my life right now, and I’m not going to spend money on medication until that is taken care of.” It’s far cheaper to help them take care of their cat, then it is for them to end up in the Emergency Department.
SARAH DASH: RoAnne, do you find that to be true? When you ask people what’s really important to them, is it actually going to get us to a more efficient healthcare system?
ROANNE CHANEY: I ran out of time, but I was going to give an example of a physician who took the time to ask somebody — because everybody always people are just non-compliant. And I always say, you ask them why, you ask them what’s going on that’s preventing them from taking a medication or doing what they are supposed to do? A local physician said he finally did that. He is rushing around and for months and months, this woman would not take this medication that was prescribed for her. He went in and he said, I’m just going to take the time. He asked the woman, what is it that was preventing her from taking this medication? She said, because her former doctor, who she loved, told her never to take it. Then he, through discussing with her, he figured out why the former physician had done that. Why it didn’t apply anymore. Was able to talk to her and have a lengthy discussion, but he firmly believed it was going to prevent a lot more medical complications down the road, by taking the time to find out why. So, yes, I think all of this that it caused, I think most of us believe it is cost effective, but we haven’t proved it yet.
BRUCE CHERNOF: The one thing I guess I would add to this, is underlying the question is: Are we paying for the right things now? So, when you look at the amount of money we are driving into healthcare right, if you look at the cost of an interaction, whether — and if you all of you just think about your own experiences, the amount of time that you spend interacting in ways with the healthcare delivery system, that aren’t actually improving the quality of your life. So, the amount of hassle or time it takes to make the amount, the amount of time that you spend filling out all of those lovely little check box forms in the waiting room. The amount of time that you spend waiting in the waiting room. I don’t know any other industry that loves waiting rooms as much as healthcare. I raise this because each of these steps costs something. So, we are actually spending a lot of money in healthcare now, in ways that doesn’t actually deliver on the promise of health. So, I do think these risk bearing models, there is an opportunity to really rethink how we deliver care. So, rather than dragging somebody all the way into the doctor’s office to be told, this is how you take your medicine, maybe I just need to be able to talk to a doctor or a nurse or a social worker, or somebody on the team who could help answer my question, that doesn’t involve all those interactions. So, I think the cost is a really fair question, but I would just challenge us to ask, are we spending our dollars today to get the value we want?
SARAH DASH: There is a question at the mic.
AUDIENCE MEMBER: Hi, my name is Emmett and I’m from Senator Whitehouse’s office. I just want to thank the panelists for taking the time to discuss this important topic. I have heard many of you discuss the wants and needs of patients. My question is: How does telehealth play a role in person-centered care? Also, what have your organizations done to improve and provide better access to telehealth services?
SARAH DASH: Thank you so much for the telehealth question, and actually that was going to be one of my next questions. Kind of piggy backing on what Bruce was saying, is maybe, is there another way to address the interaction of people with their healthcare providers? So, there was also a green card question just to add to your question, sir. The question is kind of: How does quality measurement then extend to the telehealth world?
JOHN BERNOT: I can get this discussion going, because actually this is an area where we at the National Quality Forum are really putting some energy, and actually to your question, just had a paper released at the end of August specifically on telehealth being a challenging area in quality measurement. Again, as someone who sees patients, there is a ton of promise in something like telehealth. Increasing the access for patients to — geographic access, specialist access is huge, but also taking the burden down for patients, so that they are not having transportation problems, mobility problems, getting in and out of these waiting rooms. So, there is a lot of promise. So, what our project did, was say: This area needs measurement and it doesn’t have it. So, it was a preliminary look at the field of telehealth, and broke it down by different things such as the access of care — did it improve it actually? What was the patient experience? Most importantly, what was the quality of the care delivered? Did the quality of care remotely or over some electronic format match the care that you would have received if you came in the office? So, there is quite a bit, and certainly afterwards, I would be happy to get you the full report and give you some information, but it’s a great topic and I do think it absolutely gets at a person-centered approach where we can look at the whole person, and try to perhaps pick off a few obstacles to care for those individuals.
SARAH DASH: There is a question: What were the basic conclusions of the report on telehealth? Can you go into that?
JOHN BERNOT: Yeah, I think the basic conclusion was that this level is needed. That these measures are really needed, and that’s the next step. And it actually went so far as to propose a lot of concepts. It wasn’t just high level, but within certain domains saying: Let’s get to the point where we can measure these, so we can fully assess it. But overall, really understanding and endorsing the promise that it has to offer.
SARAH DASH: Thank you, and I will ask John to give me that link, and we will make sure to put it on the Alliance website at AllHealthPolicy.org, along with the other researches for this briefing. Great, thank you, you all are a phenomenally engaged crowd, I have to say. Oh, RoAnne, you have a —
ROANNE CHANEY: I wanted to make one comment because I think it is very helpful to people, especially on follow-up. But again, it needs to be used in a personal manner. Some people don’t appreciate, they don’t want to be talking to somebody on the phone. Other people love it. So, you have to deliver it in a personal way. And not rely on it to be the solution to cutting costs. We just went through in Michigan, a huge battle with a dual demonstration about seeing someone brand new. Can you do a complete assessment over the phone? We advocated, you cannot. But there is so much that you are going to miss of that person’s environment, you can pick up things, the communication with their family, if their family is with them. You miss all of the non-verbal. Our state decides that you have to do it in person. The initial appointments have to be in person. I don’t think that is a — yes, it’s great, or no, it’s not. It is going to depend on the person.
SARAH DASH: Let me ask a question that is not on the card, but it touches on a conversation that we were having earlier, which goes to — and it does go to some of the high-touch, high-tech kind of conversation that we’re having, which is: We have a big country, rural areas, urban areas, very different kind of practice settings. Can our panelists talk about how this conversation plays out, or might play out in different kinds of geographic settings?
JOHN BERNOT: I can take that also. This is a challenge: Getting measurement done in a rural area is challenging. We didn’t go into some of the nuts and bolts of measurement, but needless to say, if you have a small population, it’s difficult to measure the — getting any validity in there to say, if you only had one patient that met a condition, it’s a zero or a 100%. That’s not a fair assessment of one’s performance. So, consequently, rural providers, and those in areas with small numbers, are often excluded from a lot of incentive programs. We did look at this particular issue in rural health and really tried to give recommendations to the field on how to include rural providers in these. I will go so far as to say, I think this is an area where we could. Because a patient voice, regardless of whether you are rural, or whether you are urban, or you have large numbers or small smaller numbers. It can be important if it’s done the right way. So, I do think it’s a good area. It could be one of those cross cutting type of topics that wouldn’t matter as much on the geographic location of the patients.
KELLY GANESAN: Just to add to what John said, and he sort of made this point as well. From a policy perspective, that idea of sort of a low volume threshold. So, clinicians that sort of see a smaller number of patients, they are excluded from a lot of those value based purchasing programs. I know that often times, those clinicians still want to collect some of that data on their patients, really to track improvement, which I think is how a lot of these measures started. So, even though it might be challenging for them to report on certain measures, given kind of the volume of patients, or where they are located, a lot of them still have interest in collecting that information to showcase improvement.
SARAH DASH: Okay. I want to get to a couple of questions that people have asked about kind of trade-offs of sort of this idea of person-centered care quality measures. And then I want to get to a set of questions around implementation, implementation at the health plan level, state level and federal programs. The questions around — I guess what you could kind of call trade-offs, is one person asks: How should providers balance times when patient goals might be at odds with a larger societal goal? And they raise the example of opioids, where someone’s idea of pain control might mean, perhaps more opioids as opposed to something that maybe wouldn’t contribute to the opioid crisis. And then another person asks: How do you draw the line between patient-centered care, where the patient can ask for what they want, versus the physician using their expertise to say what they think is best for the patient’s health. So, can you all kind of address what I’m sure are questions that you’ve thought about extensively?
ERIN GIOVANNETTI: So, the opioid situation came up, and actually one of — two of the encounters that I observed as part of the evaluation of what we did, where somebody — this was two different people wanted opioids for pain, and they were very frustrated that the provider was not giving them the opioids for pain. And I saw this work out in two different ways. One, was that the provider spent a long time sitting down with the individual and talking about a pain clinic, and eventually got the person to agree that a pain clinic was the better approach than to go on an opioid. The other, where the provider said, okay, we will talk about it next visit. And pushed it off to the next one. I don’t think there is a right answer. There is always going to be difficult situations where someone is asking for something that may not be necessarily the right thing for them, for their health, for the people around them, or for society. And we as quality measured developers cannot come in and stick our nose in the middle of that clinician/individual relationship. We have to rely on clinicians being able to use judgement to do the right thing in those situations. But I don’t think that our fear of tradeoffs and those situations should keep us from doing this type of measurement. When we started this work, we heard a lot of people saying, “This is not going to work, because individuals are going to ask for unreasonable things. They are going to have unreasonable outcomes that they want to achieve.” I want to cure my dementia. We can’t hold clinicians accountable for that. When we started doing it, that’s not what happened. Actually, most of the time, people were setting goals, the clinician said, “This is too modest a goal. You could achieve more than this.” So, sometimes I think our fear of what we think is going to happen, keeps us from moving forward in areas where we actually could make change.
SARAH DASH: RoAnne, you look like you have something.
ROANNE CHANEY: I did have something to say, because I thought part of the whole person-centered process is also offering people options and is being very straight with the consequences; that one option may bring, that another one doesn’t, in terms of what happens if you follow one optional treatment. In working with a lot of people, I have found that sometimes, providers are reluctant to tell people the negative consequences of their decisions. We generally kind of advocate. You’ve got to be straight with people about what’s going on. Actually, in the opioid issue, we’ve looked at some data from our home and community based services, and there was very high pain indicators that people were experiencing a lot of pain who were on the waiver program. And the consumer quality collaborative said: We look at that, why is that? Well, it turned out that half of the people that had been prescribed pain medication, were not taking it, because they didn’t like the side effect of being groggy, and not able to function or focus on the things in their life they wanted to focus on. And they were actually making a decision to experience more pain than take those medications that were causing that grogginess. So, I think there are a lot of issues in that, in terms of people getting the full information they need to make a decision for themselves.
JOHN BERNOT: I will just add one more. I happened to be at a conference about a week ago, a primary care measurement conference, and the same issue came up. And one of the strategies — and this is maybe taking my NQF hat off a little bit and getting into a clinician, but one of the strategies that we had discussed there was really this concept of the co-development of goals. And if that step occurs, then we don’t really run into the same problem, because we would not co-develop a goal where you are getting 20 Oxycodone in a day. That would not be a co-developed goal. So, once we get that agreed upon co-developed goal, then these things can move forward. I also agree with Erin, that I think we don’t have — we have a lot of fears, and we put the fear first sometimes, that all of these things are going to break down and what if, what if, what if? But I would suspect, and this is speculation, that we saw this in process measures earlier. This isn’t going to work. Then they work themselves out. I think moving these measures forward is till the right thing to do. Are they ready for payment programs? Perhaps not yet, but I do think still, we will be learning a lot about how the patients are interpreting these, and likely, in my opinion, will be pleasantly surprised at the results that we get from these types of measures.
SARAH DASH: I want to get to a whole series of questions that we have about implementing these measures in terms of payment and other alternative payment models, et cetera, but I want to get to the question at the mic first.
AUDIENCE MEMBER: First, I just want to say how much I honor the work that all of you are doing. As somebody with a background in public health, from Harvard University, where I’ve done both research as well as practice related to a lot of the concepts that we are discussing today. Some of my background is also related to psychology and sociological aspects of — really related to the efficacy of care. I want to point out, and I wonder — you know, thinking forward about how can we really get the need for these measures really understood by the decision makers and just really with the country as a whole. When you look at the data of how mind and body are related, and how a person’s intrinsic motivation and just feeling that they are invested in their care, we know that psychologically as well as with their social environment. It’s so key to know, does somebody have somebody to take them to the doctor? Do they have somebody who can listen when they have a concern? This gets into the care giver, obviously, but also the broader, social community. So, there is a wealth of evidence that shows that if certain aspects of an individual are not there, you can prescribe all the medication you want, but are they going to take it? And will they take it when? How will they need it? If somebody is depressed, anxious, or has a number of other things — I worked with heart patients and at a high level, of somebody has psychological issues where their will to live is not there, the system is spending money and time to provide this care, but if some of these things that attend to the person-centered care are not acknowledged at all, we have wasted a lot of money. I just wondered how familiar you are with some of this research and I can’t help but think that it would add a really strong case for exactly what you are doing.
SARAH DASH: Thank you for the comment, and I think it goes to some of the questions that we were talking about earlier with regard to patient engagement and motivation as opposed to kind of this idea of compliance or adherence. But I will stop my editorializing and see if anyone wanted to comment.
ERIN GIOVANNETTI: Thank you, I think you are entirely right. There is a lot of evidence out there about patient engagement and how to actually get people engaged in their care. Where I come in is saying: Okay, we know what’s right, maybe there is evidence for it, maybe there is not, maybe we just know it’s right. How do we measure whether it’s actually happening? Because we are not there in the room observing and we are not listening to the conversation. How do I know from what’s being documented, whether or not it’s happening? So, that’s where I think we struggle with it still.
SARAH DASH: Okay. We have some really great questions up here about implementing all of the ideas we have talked about, and kind of the payment programs, and so let me kind of start and I will try to do my best to combine them so we can get as much of a commentary as we can. One question is: What are key issues or considerations for health plans or states that are hoping to tie person-centered outcomes to alternative payment models? There is a related question about whether there are examples of managed care plans, state governments, or health systems that are using quality measures to re-design coverage programs and even go into supporting patients outside of the medical setting. So, I will try to combine those two questions: What are the key issues or considerations for implementation, and then, are there are some good examples out there?
NELLY GANESAN: I can speak to that first. There are — so, a lot of what is happening, at least on the alternative payment model side, from a managed care plan perspective; some of what they are doing is actually being adopted from what’s happening with Medicare, and sometimes it goes by, so I think sometimes with the initial rollout of what was the Accountable Care Organization on the Medicare side, there were some lessons learned from plans in terms of how those measures were being adopted. I think historically speaking, what plans do, sort of what the private plan market is doing in terms of the types of measures that they are including, isn’t necessarily made public, but they go about it in a couple different ways. One, they use a number of measures for their different alternative payment models. Two, they sort of, especially on the patient reported outcome side, do build sort of homegrown measures that they may use internally. Then third, if there are measures that are being used in the Medicare program, that aren’t NCQA measures or developed by other entities, they do tend to adopt those measures. To answer the second question, I think there are a number of sort of good models to look at. I think the one that comes up a lot in these types of conversations is the alternative quality contract model with Blue Cross/Blue Shield of Massachusetts. They have a good set of measures that are sort of publicly made available and they have a number of different sort of measures that also look at not only patient reported outcomes, I think the one that they use is called the PHQ9, that assesses depression, that I’m sure this whole panel is very familiar with. And they have adopted — they are working on developing some additional measures to include in that value-based contract as well.
ERIN GIOVANNETTI: I was recently at a health plan, and they told me about their health fair that they were having, and they said, the health fair is so that we can get everyone to come in, and they can get their HEDIS measures. I said, what do you mean, get their HEDIS measures? They said, so we can check off all those HEDIS measures we have to report on. So, they were having people come in and get their eyes scanned and their hemoglobin A1C checked and their blood pressure checked, and I didn’t think of this as, we are doing this because we are getting all of these preventive health things in, they thought of it as, we are doing it to get all of our HEDIS measures checked, which is not the way HEDIS was every intended to be used, so that you would have a way to meet all your HEDIS measures. So, every time I hear about HEDIS measures being used to transform systems, I think about some of the limitations of our HEDIS measures set. That being said, what do I think are the most exciting quality measures that are out there right now for doing some of this? We are about to introduce a new set of HEDIS measures focused specifically on long term services and supports that I think are starting to get at some of these more non-medical aspects around assessment and care planning, that I think are going to be really great. There is also some really exciting work coming out of — actually, recently endorsed measure of experience with home and community-based service providers. Also, getting at that type of patient-centered care, as what are your actual experience with those people that are coming into your home on a regular basis to help you out. Another quality tool that I find very useful is the national core indicators, is another one. They have an aging and disability survey that looks at a state. Also, it’s being used at a health plan level, looking at some of these outcomes, and it’s a really well-done survey. So, those are my suggestions.
SARAH DASH: Thanks. Anyone else want to weigh in on that question? Great. Okay, so there is another question here, and there was a recent MedPAC recommendation that the MIPS program, which is part of the — I’m going to use a lot of acronyms, so I am sorry, in the last ten minutes of the briefing. The MIPS program, which is part of the recent MACRA legislation, the whole quality payment program, how physicians are paid in Medicare. That program should be eliminated and revised. So, the question for the panel is a little bit of an unfair, like, look in your crystal ball kind of a question. But the question is: What’s the likelihood that HHS will follow that recommendation? But perhaps, more to what you could speak to, what impact would that have, if any, on measuring patient-centric outcomes?
ERIN GIOVANNETTI: So, from my experience of working on measures that will be used to MIPS, if MIPS moves forward. I can’t speak to whether or not it’s going to move forward. Probably it will. But I can say, one of the challenges we have, is a bit of a chicken and an egg thing. We can only measure what’s currently being documented, but we want to measure things that aren’t being documented. So, how do we get ourselves to a point where — so, if I take for example, measures around — let’s just take rheumatoid arthritis and wanting to have person reported outcome measures in rheumatoid arthritis. In order to get a measure into MIPS, you have to go through a whole process of testing, NQF endorsement, all of those sorts of things. Except, no one is collecting person-reported outcome measures on rheumatoid arthritis. So, how do you test the measure then, to get it into the program, to then get it measured, so that people start collecting information? So, I think we have a lot to work through still, in terms of using quality measures to drive system transformation when quality measures have to be based off of the practices that are going on now. I think we still have that challenge to overcome.
SARAH DASH: Thank you. There is one more question that I want to try to fit in, which relates to nursing home care. How do you see these elements being incorporated into the highly regulated world of nursing home care? If you can get to that.
ERIN GIOVANNETTI: So, one of the sites in our pilot actually did this on nursing homes settings. I think that the piece that we did around goals works perfectly well in a nursing home, community setting, because it’s really about what do you want to achieve? And it’s person driven; it’s decided by the person. I have hopefulness that this approach could actually be something used across any delivery system, any type of provider, because it’s based off of what somebody wants at that individual time.
SARAH DASH: We have about five minutes left in our briefing time. I want to thank those of you who have stayed with us. I’m going to ask one final question of our panelists as you prepare to wrap up the briefing. We have blue evaluation forms, we appreciate if you could just fill those out before you head out. I want to ask everyone if they could maybe spend a minute talking about, where do you see quality measurement going in the future, and how does that relate to the person-centered principles that we’ve been talking about today? We will just go down the line and start with RoAnne, if that’s — if I can put you on the spot to go first.
ROANNE CHANEY: I would say some of — it’s good to hear from this panel, and it is going where I think it’s going, more towards patient-centered outcomes. Patient-reported outcomes. I hope that’s where we are going, because I think we will get to more of what’s important to the person themselves by doing that. There is a lot of work to do yet, though.
BRUCE CHERNOF: I guess I see us getting to a point where there is — it’s a scale with two platforms. So, technical quality of care will always be really important. But we are also going to get to a place where personal experiences and goals are also really important. So, quality of life and quality of health, and that those are balanced against one another. I think sort of extending on that for one second, I would say that it gets to a place where I sense that there is a lot of fear in the healthcare delivery system about actually asking people’s experience in their goals, and what the work of these really talented panelists shows, is that you can actually ask these questions in ways that are important, that people or patients actually underestimate what they can achieve, and by activating them, even if they don’t achieve their goals, they actually may be more satisfied, that outcomes may be better. So, to me there is this real opportunity to sort of beat down the fear quotient and move to something that in the long run, I think healthcare providers and delivery systems would find more rewarding.
ERIN GIOVANNETTI: I think the majority of our healthcare quality measures have focused on the largest population right now, which is generally healthy adults. Prevention. I think we are going to move much more towards more quality measures focused on very specific high need, high cost populations where we can actually start to move the needle on value.
JOHN BERNOT: I totally agree, exactly, Bruce said it marvelously, that there is going to be a balance between this patient-centered approached and then the clinical indicators of quality that we are so used to using. And I definitely think I see that going. I think outcomes in general are where we will move, getting away from processes and trying to get the right responsibility or attribution level around outcomes. The other thing that hasn’t been mentioned specifically, is the impact of the social determinants of health, disparities and equity on the measures, I think will be a topic of discussion, certainly for the next couple of years, to see how that all fits into this picture.
NELLY GANESAN: I would agree with everything that has been said, especially with what Erin said, around measures that are developed for sort of this high-need, high-cost population. I think that where we can start to see some real change is probably in that area. Then the other thing I would just add is –not that this is the question, but sort of what I hope, is that the focus of measurement isn’t always linked to payment. I know that that’s kind of where we are today, but the initial sort of reason why a lot of these measures were created, was really to sort of improve outcomes and with an overall focus on payment, I think we start to lose that. So, hopefully that doesn’t override the initial thought process.
SARAH DASH: Well, thank you, and I would like to thank all of our panelists for lending their expertise. I would like to thank all of you. Honestly, this is the most green cards I have gotten in any briefing in this entire year, so thank you for being such an engaged audience. We really appreciate you spending your Thursday afternoon with us. Thank you to the SCAN Foundation for supporting this briefing, and please join me in thanking our panel.