Stephen M. Schleicher

Health Care Delivery Innovations That Integrate Care? Yes!: But Integrating What?

To enable improved cost control, quality, and access, US health care delivery is moving from fragmented fee-for-service delivery into various innovative integrated models, including accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and bundles, defined as a coordinated group of services for a specific need, administered over a predefined period. These innovations hold promise for patients whose complex care requirements account for the bulk of health care costs and who would reap the most benefit from a coalesced network of care.

Outcome measurement in value-based payments

Value in health care, the balance between outcomes that matter to patients and the costs required to achieve them, is being increasingly recognized as a path to health care reform. The Department of Health and Human Services recentlyannouncedits intentiontotie50%oftraditionalfeefor-service payments, made by the Centers for Medicare and Medicaid Services (CMS), to value or quality through alternative payment models (APM), including accountable careorganizations(ACOs)andbundledpayments,by2018.1 The Centers for Medicare and Medicaid Services is also payingspecialattentiontocancercare,sinceitaccountsfor nearly

Medication overuse in oncology: current trends and future implications for patients and society

125billioninmedicalspendinganddatarevealswide variations in the cost of care delivered with no relation to survival.2 As APMs become more commonplace and value becomes the global metric certain challenges arise. To address the numerator of the value equation we must develop, test, endorse, and use meaningful outcomes measuresfortheserviceshealthcaresystemsprovide.Currently, there are an overabundance of validated process measures, and a paucity of outcome measures. As policy experts have noted before, a quality measurement approach that is wholly reliant on process measures misses 2 important facts: patients care more about the results of their care than how these outcomes are achieved, and process measures might contribute to but are not surrogates for outcomes, and omit factors such as staffing patterns, interdisciplinary communication, supportive infrastructure, and transitions of care. However, measuring and reporting outcomes that matter to patients has proven to be difficult, and are especially challenging in cancer, as evidenced by the slow pace of measure development and adoption over the past 2 decades. In 1999, the Institute of Medicine (IOM) published Ensuring Quality Cancer Care,3 an influential report that generatedmuchfervor. Itdescribedanaspirationalcancercare system and issued 10 recommendations to address pervasive gaps in the delivery of quality care. As of 2014, these recommendations remained largely unfulfilled.3 Further evidence comes from the Department of Health and Human Services, which commissioned the National Quality Forum (NQF) in 2010 to identify areas where outcome measures were needed but not yet developed. The resulting gap analysis found that very few outcomes measures for cancer had been endorsed, and those that have were focused primarily on end-of-life care.4 To update that analysis, we compared quality measures for colorectal, breast, prostate, and lung cancer, endorsed by the NQF, ASCO’s Quality Oncology Practice Initiative (QOPI), and the International Consortium for Health Outcomes Measurement (ICHOM), as well as those that are being tracked by several major APMs including Medicare Shared Savings ACOs, the PPSExempt Cancer Hospitals Quality Reporting Program, and the Oncology Care Model (OCM). As shown in the Table, all of QOPI’s measures, and the majority of NQF’s measures represent process measures. Moreover, none of the APMs plan to track actual outcome measures. The quality measures that will be used in Medicare’s upcoming Merit-Based Incentive Program are yet to be finalized, so they were not included. Insomerespects,itisnotsurprisingthatidentifyingand measuring meaningful outcomes in oncology is difficult. Cancer represents a wide spectrum of heterogeneous diseases, and a detailed outcome measure may be applicable to a limited set of patients in any given time period. In addition delivering cancer care is complex owing to its multi-disciplinary nature (though some cancer centers are starting to collocate multiple treatment and palliative disciplines).Furthermore,canceroftendoesnotfollowthelinear progression of disease morbidity of other chronic diseases, such as heart failure or diabetes, but rather adheres to a winding course that can abruptly shift in acuity. Finally, quality measures that would apply to patients in the adjuvant setting may no longer apply when patients develop treatment-refractorydiseaseandarepursuingcomfortcare. But although developing sound outcome measures is hard, it isnotimpossible.TheICHOMhasusedglobalteams ofphysicianleaders,outcomesresearchers,andpatientadvocategroupstoproposecancerdisease-specificstandard outcomemeasures(Table).ComparedwithNQF,QOPI,and APM measures, ICHOM places a larger emphasis on PROs, previously highlighted in the NQF’s gap analysis. Whereas the ASCO Quality of Care Committee has focused on using PROs to assess pain and chemotherapy-induced nausea and vomiting, ICHOM has gone a step further to assess important PROs specific for each common cancer type, such as sexual dysfunction and incontinence in prostate cancer, to address the heterogeneity of this disease.5 Notably, the OCM requires a documented care plan that contains the 13 components of the IOM’s care management plan, which include items such as goals of treatment, estimated out-of-pocket costs, defining physician responsibilities (oncologist vs primary care physician), expected effects on quality of life, and posttreatment surveillance plans.6 Although care planning is not outcome measurement per se, this care plan represents an opportunity to improve patient engagement and move closer to the value agenda. The inclusion of the care plan in the OCM does represent CMMI’s ability to adopt measures not previously vetted by the NQF and CMS in a pilot program that may set the way for more rapidly testing true outcome measures in upcoming CMMI programs. It remains to be seen whether such accelerated adoption of measures that proffers the opportunity to quickly iterate and pivot is ultimately a better strategy than rigorously testing and validating measures in controlled experimental settings. What is needed now is an accelerated path for cancer outcome measures to be tested and endorsed through the NQF-convened collaborations. To their credit, the NQF VIEWPOINT

Alternative payment and care-delivery models in oncology: A systematic review: Payment and Care-Delivery Models

The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse.

How the affordable care act has affected cancer care in the united states: Has value for cancer patients improved?

Rising US health care costs have led to the creation of alternative payment and care‐delivery models designed to maximize outcomes and/or minimize costs through changes in reimbursement and care delivery. The impact of these interventions in cancer care is unclear. This review was undertaken to describe the landscape of new alternative payment and care‐delivery models in cancer care. In this systematic review, 22 alternative payment and/or care‐delivery models in cancer care were identified. These included 6 bundled payments, 4 accountable care organizations, 9 patient‐centered medical homes, and 3 other interventions. Only 12 interventions reported outcomes; the majority (n = 7; 58%) improved value, 4 had no impact, and 1 reduced value, but only initially. Heterogeneity of outcomes precluded a meta‐analysis. Despite the growth in alternative payment and delivery models in cancer, there is limited evidence to evaluate their efficacy. Cancer 2018.