Tracy E. Spinks

Ensuring quality cancer care: a follow-up review of the Institute of Medicine's 10 recommendations for improving the quality of cancer care in America.

Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US health care system in the late 1990s. The National Cancer Policy Board (NCPB), a 20‐member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system in which patients would have equitable access to coordinated, guideline‐based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. The report outlined 10 recommendations, which, when implemented, would: 1) improve the quality of cancer care, 2) increase the current understanding of quality cancer care, and 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating health care costs, has prompted national efforts to reform the health care system. These efforts by health care providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States. Cancer 2011;.

Improving Cancer Care Through Public Reporting Of Meaningful Quality Measures

Historically, quality measures for cancer have followed a different route than overall quality measures in the health care system. Many specialized cancer treatment centers were exempt from standard reporting on quality measures because of the complexity of cancer. Additionally, it has been difficult to create meaningful quality measures for cancer because the disease can strike so many different organs; is discovered at and progresses through different stages; and is treated using different modalities, such as surgery, radiation, and chemotherapy. Over the past decade the National Quality Forum, a nonprofit organization dedicated to bettering the quality of US health care, has endorsed measures of quality for cancer providers and patients. The Affordable Care Act of 2010, which has sections specific to cancer reporting, will also further the development and public reporting of cancer quality measures-important steps in improving the delivery of cancer care.

Value-Based Breast Cancer Care: A Multidisciplinary Approach for Defining Patient-Centered Outcomes

PurposeValue in healthcare—i.e., patient-centered outcomes achieved per healthcare dollar spent—can define quality and unify performance improvement goals with health outcomes of importance to patients across the entire cycle of care. We describe the process through which value-based measures for breast cancer patients and dynamic capture of these metrics via our new electronic health record (EHR) were developed at our institution.MethodsContemporary breast cancer literature on treatment options, expected outcomes, and potential complications was extensively reviewed. Patient perspective was obtained via focus groups. Multidisciplinary physician teams met to inform a 3-phase process of (1) concept development, (2) measure specification, and (3) implementation via EHR integration.ResultsOutcomes were divided into 3 tiers that reflect the entire cycle of care: (1) health status achieved, (2) process of recovery, and (3) sustainability of health. Within these tiers, 22 patient-centered outcomes were defined with inclusion/exclusion criteria and specifications for reporting. Patient data sources will include the Epic Systems EHR and validated patient-reported outcome questionnaires administered via our institution’s patient portal.ConclusionsAs healthcare costs continue to rise in the United States and around the world, a value-based approach with explicit, transparently reported patient outcomes will not only create opportunities for performance improvement but will also enable benchmarking across providers, healthcare systems, and even countries. Similar value-based breast cancer care frameworks are also being pursued internationally.

Development and Feasibility of Bundled Payments for the Multidisciplinary Treatment of Head and Neck Cancer: A Pilot Program

PURPOSE Despite growing interest in bundled payments to reduce the costs of care, this payment method remains largely untested in cancer. This 3-year pilot tested the feasibility of a 1-year bundled payment for the multidisciplinary treatment of head and neck cancers. METHODS Four prospective treatment-based bundles were developed for patients with selected head and neck cancers. These risk-adjusted bundles covered 1 year of care that began with primary cancer treatment. Manual processes were developed for patient identification, enrollment, billing, and payment. Patients were prospectively identified and enrolled, and bundled payments were made at treatment start. Operational metrics tracked incremental effort for pilot processes and average payment cycle time compared with fee-for-service (FFS) payments. RESULTS This pilot confirmed the feasibility of a 1-year prospective bundled payment for head and neck cancers. Between November 2014 and October 2016, 88 patients were enrolled successfully with prospective bundled payments. Through September 2017, 94% of patients completed the pilot with 6% still enrolled. Manual pilot processes required more effort than anticipated; claims processing was the most time-consuming activity. The production of a bundle bill took an additional 15 minutes versus FFS billing. The average payment cycle time was 37 days (range, 15 to 141 days) compared with a 15-day average under FFS. CONCLUSION Prospective bundled payments were successfully implemented in this pilot. Additional pilots should study this payment method in higher-volume cancers. Robust systems are needed to automate patient identification, enrollment, billing, and payment along with policies that reduce administrative burden and allow for the introduction of novel cancer therapies.

Quality Measures for Oncologic Emergency Medicine

Cancer patients experience a number of quality of care issues in the emergency department (ED) and in other healthcare settings. Routine measurement and public reporting of the outcomes, processes, and structure of care has been recommended as an important policy lever to increase provider accountability and, ultimately, improve the quality of care. However, quality measure development for oncologic emergency medicine has lagged behind other conditions and care delivery settings for more than a decade. Thus, ED-based oncology care is largely excluded from the current national quality reporting programs. To address this gap, we advocate the implementation of a national quality reporting program for cancer care, in harmony with recent recommendations from the Institute of Medicine. With formal national leadership, adequate funding, multi-stakeholder collaboration, and a robust and transparent health information technology infrastructure, this program could do much to increase the transparency and quality of oncologic emergency medicine across the nation.

Implementing value-based cancer care: A multidisciplinary approach to defining breast cancer outcomes.

16 Background: Value in healthcare (patient-centered outcomes achieved per dollar spent) unifies performance improvement goals with health outcomes of importance to patients. We describe the process through which value-based measures for breast cancer patients and dynamic capture of these metrics via our new electronic health record (EHR) were developed at our institution. METHODS A review of the breast cancer literature was conducted on treatment options as well as expected outcomes and potential treatment complications. Patient perspective was obtained via focus groups. Multidisciplinary teams met to inform a 3-phase process of (1) concept development, (2) measure specification, and (3) implementation via EHR integration, planned for spring 2016. RESULTS Outcomes were divided into 3 previously defined tiers (NEJM 2010; 363:2477-2481) that reflect the entire cycle of care (Table).Within these tiers, 22 patient-centered outcomes were defined with inclusion/exclusion criteria, specifications for reporting, and sources for data including the EHR and validated patient-reported outcome questionnaires (e.g., FACT-B+4) administered via our patient portal. CONCLUSIONS A value-based approach to cancer care with transparently reported patient outcomes not only creates opportunity for performance improvement but also enables benchmarking within and across providers, healthcare systems, and even countries. Our value-based framework for breast cancer is the first of its kind in the United States, with a similar model being pursued internationally as well. [Table: see text].

Measuring value in bundled payments for head and neck cancer.

11 Background: Value, defined as outcomes relative to costs, cannot be improved without rigorous long-term measurement. To assess value within a bundled payment pilot for head and neck cancer, we aim to generate timely, patient-centered outcomes and robust, near-real time financial tracking (Porter and Teisberg, Redefining health care. Creating value-based competition on results; Harvard Business School Press, 2006). METHODS Clinical and quality experts created an outcome measure set for head and neck cancer, using a three-tiered outcomes hierarchy from Michael Porter of Harvard Business School as a framework. Process measures were identified to evaluate compliance with standards of care. Data sources were verified and patient-reported outcomes were collected via a patient portal. A REDCap database was created to aggregate all longitudinal outcomes. The project managers and financial leaders identified key financial metrics to be tracked for enrolled patients. Outcomes and financial data were built into a dashboard to deliver timely, actionable information on value. Patients will be tracked for 2 years post-treatment completion. RESULTS 22 outcome measures and 6 process measures are being collected for all enrolled patients. Financial indicators, such as cumulative costs and fee-for-service payment vs. bundled payment, are being tracked for each patient. Currently, most outcomes and financial data are extracted manually. Implementation of a new electronic health record (EHR) should alleviate much of this administrative burden (Table). CONCLUSIONS The project demonstrates the feasibility of value measurement for bundled payment. With provider and patient input, the outcome measures direct attention to what is important to patients and is actionable by clinicians. Additionally, near real-time financial tracking offers insights into the financial implications of this alternative payment model for cancer care. With automation via the EHR, this value measurement methodology can be scaled for other disease sites and additional payers. [Table: see text].

Lessons learned from a cancer center-specific federal quality reporting program.

42 Background: As part of the Affordable Care Act (ACA) of 2010, the Prospective Payment System-Exempt Cancer Hospital Quality Reporting (PCHQR) Program was created for 11 cancer centers. PCHQR includes an initial set of 5 measures mandated for federal reporting and expanded to include 18 measures for subsequent program years. The Alliance of Dedicated Cancer Centers (ADCC) formed in 1983 to include and represent the interests of the same 11 centers. As a small and previously organized group, we have been able to collaborate closely throughout implementation of PCHQR to understand, evaluate, and offer feedback on the program. METHODS The ADCC began sharing and reviewing data on mandated measures upon the release of the ACA in 2010. Numerator and denominator data for measures are manually uploaded from each center to a common master file bi-annually. In December 2013, ADCC hospitals formally began sharing feedback on concordant and non-concordant cases through email, bi-annual in person meetings, and monthly teleconferences. RESULTS Through sharing feedback on data submission with each other, CMS, and CMS contractors the ADCC learned the following lessons: 1- Limitations exist in the submission of our current data sets, (e.g. inability to accurately capture all scenarios that lead to appropriate delays in treatment). 2- Process of care measures are topped out with aggregated values above 95% for multiple consecutive quarters. 3- 4 of the existing measures and multiple forthcoming measures have case selection criteria creating sample sizes of little comparative value or statistical significance. 4- Tertiary care centers share many unique treatment patterns affecting compliance (e.g. lag time from referral to diagnosis, high percentage of patients on clinical trials). 5- Subject matter experts embedded at the 11 centers are critical for measure development/ refinement (e.g. Tumor Registrars, ICPs). 6- CMS, CMS contractors, and affected hospitals must establish effective communication channels. CONCLUSIONS Our early experiences indicate it is challenging to apply broad national measures to the ADCC hospitals. The 11 centers seek to continually improve upon this mandate and advance clinical practices.

A patient-centered outcome measurement approach for bundled payments in cancer care.

266 Background: The project aims are to: 1) apply a patient-centered approach to evaluate quality of care in a bundled payment pilot for head & neck cancer; and, 2) measure quality at the condition-level; and, 3) incorporate patient-reported outcomes (PRO) in routine quality assessments. A three-tiered outcomes hierarchy developed by Michael Porter of Harvard Business School is used to define outcome measures, to be used for quality improvement and reporting during the pilot. Porters model evaluates outcomes over the full cycle of care, examining: (1) health status achieved/retained; (2) recovery process; and, (3) health sustainability. [Porter, M.E. (2010). What is value in health care? N Engl J Med, 363(26), 2477-2481. doi: 10.1056/NEJMp1011024.] Methods: An 11-member team of clinical, quality, data, and IT experts identified measure concepts, developed measure specifications, and implemented reporting. The project lead interviewed clinical experts to gain consensus around a focused set of measures and benchmarks. Measures were evaluated for importance to patients using feedback from patient focus groups. The team defined the measure specifications (numerator, denominator, etc.), selected a validated PRO instrument, and developed the work flow and tools for data collection and reporting. Process maps were created for training and reference purposes, and clinic staff trained. Testing was completed prior to implementation, with periodic process checks and additional staff training, as needed. RESULTS Measure development and implementation were completed using a streamlined approach over a 6-month period and required 12 team meetings before implementation. The project leveraged existing data streams, where possible, and IT development focused on quick-turnaround solutions. CONCLUSIONS The project demonstrated that patient-centered outcomes measures can be developed and implemented in a compressed time frame. With provider and patient input, the measures focused on outcomes that are important to patients and actionable by clinicians. This created a scalable framework to be implemented in other disease sites and integrated into our EHR.