Mark McDonald, MD, of the Emory University School of Medicine, discusses value-based healthcare in the US and the potential benefits it could deliver for both patients and providers. Dr. McDonald covers the lead-up to this new care model, how the transformation will look for oncology, and how electronic patient reported outcomes (ePROs) are integral to a deeper understanding of the impact of disease and treatment on patient quality of life and the digital patient journey.
How do you define value-based healthcare (VBHC)? Is this definition the same in oncology, as it is for other medical specialties? If not, how does it differ and why?
Value-based healthcare is a structural change in how we pay for healthcare delivery. Rather than being paid for what we did, we would be paid for how we did. In other words, payment would be based on delivering outcomes rather than providing services. The value comes from considering the cost of the interventions against the outcomes that were obtained, driving the system towards lower cost solutions that yield the same or better outcomes. The Centers for Medicare & Medicaid Services (CMS) has defined three aims for value-based programs: better care for individuals, better health for populations, and lower cost.
I do not believe the definition of value-based health care is different in oncology, but certainly my bias is that the complexity of defining and delivering value is substantially greater in oncology based on a several factors:
- the multidisciplinary nature and complexity of cancer care
- the diversity of cancer types and presentations
- the necessity of personalizing care not just to the genomics of the disease but to the health, circumstances, and expectations of the patient
- the often open-ended nature of the disease course
- the impact of late toxicities which may occur years or decades after treatment
Download the Emory Proton Therapy Center abstract, Integration and Utilization of Electronic Patient Reported Outcomes (ePROs) in a Radiation Oncology Practice for Value-Based Care.Get abstract
What are the concept’s roots and how has it changed since it was introduced?
The motivation to transition away from our current fee for service payment system to value-based healthcare is based on the widely acknowledged problem of unsustainable healthcare expenditures in the US.
Current efforts and models originate from the efforts of the Center for Medicare and Medicaid Innovation (CMMI), which was created by the Patient Protection and Affordable Care Act of 2010. Passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 has accelerated the transition to value-based payment models in Medicare. CMMI has developed many models for alternative payment in healthcare, and these models have undergone iterations in development with input from multiple stakeholders.
What are the benefits of a VBHC model for patients? For providers?
In the optimal implementation, value-based healthcare would benefit everyone. Patient care could be improved because the care team may have a motivation to invest additional resources and education to help avoid expensive episodes of care like emergency room visits and hospitalizations, to avoid unnecessary or duplicative tests, and aligning care with evidence-based care plans.
Providers could benefit from streamlined billing requirements that focus attention on quality measures and outcomes over documenting a high volume of services provided. Such a utopian outcome is unlikely to be the result of a move towards value-based healthcare, but improvements to the current state are certainly possible.
What are some barriers to value-based care adoption in oncology?
While few would argue with the goals of value-based care, when considering such dramatic changes in healthcare payment, the devil is certainly in the details. There are legitimate concerns about unintended consequences of implementing untested changes in healthcare payment which could stifle innovation in the development of new drugs, devices, and treatment approaches, interfere with personalized medicine and the doctor-patient relationship, and impose significant additional regulatory burden on providers in data collection and reporting.
Many providers feel they are already spending too much time checking boxes, lessening the time available for meaningful engagement with patients. And naturally people have concern and anxiety about how “the system” will balance cost and quality, how quality is assessed (are the metrics meaningful and patient-centric), and how their role in patient care may change.
Is VBHC reporting mandated by any governments?
For radiation oncology in the United States, the upcoming Alternative Payment Model is the first mandated test of a shift towards value-based healthcare in the US. Slated to start July 1, 2021, participation is mandatory for the 30% of practices who were randomly selected by ZIP codes across the country. In the model, a fixed payment is made for Medicare patients receiving radiation therapy based on the patient’s diagnosis, and the payment is the same whether radiation is delivered in a hospital-based or free-standing facility, and regardless of the type of radiation employed or the number of treatments delivered. The model is intended to run for five years and provide data to compare cost of care against the control cohort of providers who were not randomly selected for participation. The model also includes reporting on four quality measures and clinical data reporting.
Can tracking patient reported outcomes (PROs) add value to patient engagement in their care pathway?
I do think many patients appreciate the value of patient reported outcomes instruments to provide feedback on their care, because many PRO instruments capture more comprehensive and holistic assessments than what we can hope to glean in the timespan of a typical patient encounter. PROs most often assess not just symptoms, but the impact of symptoms on patients’ functional status, their emotional well-being, their interpersonal relationships, satisfaction and overall quality of life. Caring for the “whole person” certainly requires a better and fuller understanding of the patient, and by using validated PROs we can obtain complex and multidimensional information systematically, relatively efficiently, and in a quantifiable way with normative data to contextualize the results.
PROs can add value through the course of patient care when the clinical team recognizes changes and takes appropriate interventions to address deteriorating PROs. We are all accustomed to using a patient-reported pain score, and adjusting our interventions based on those changes. Imagine if we never asked the patient to report their pain and based our interventions on our own perception of the patient’s level of discomfort. I think we would miss a lot, probably all but the direst pain. While a pain score focuses on one issue, with PROs, we can obtain similar levels of insight in a more complete assessment of the patient’s health status throughout treatment and guide earlier interventions without waiting for catastrophic levels of dysfunction to manifest.
PROs can also add value in understanding, measuring, and comparing the outcomes of our healthcare. While it is not certain if value-based care models will ultimately include requirements for more comprehensive collection of patient-reported outcomes, or potentially even associate aspects of reimbursement to PRO outcomes, PRO data are increasingly important when assessing or comparing treatment approaches and are likely to become a more critical data element for innovation and new treatments in an increasingly cost-conscious healthcare system.
Are electronic patient-reported outcomes (ePROs) standard of care for your facility? At the point of care, follow-up or both?
Systematic collection of PROs for all patients is not yet a standard across our department. When we laid out our vision for our new practice site at Emory Proton Therapy Center, we set out to implement standardized collection of PROs for every patient treated with this specialized radiation modality. We collect baseline (pre-treatment) PROs, weekly measures during treatment, and at specific time points after completion of therapy. Based on the great work and publications by several other institutions, we knew that implementing PROs in the oncology setting was an achievable goal that improves patient care, and we knew that electronic PROs would be essential for data completeness, accuracy, and usability.
How has the evolution of ePROs shaped the standard of care and real-world evidence research for you and at your facility?
Implementing electronic PROs has required a significant investment in time and resources. There was an investment in IT and implementation, but it also requires training and a shift in mindset by the entire team. For our genitourinary providers, routine PROs like EPIC and AUA scores have long been an ingrained part of their clinical practice and the team understands how these PROs provide actionable information that informs treatment options and management. But the same is not true in most subspecialties, where PROs are less familiar and there is little experience or data on how to use these PROs to inform patient care. So, I would say that the integration of patient reported outcomes is still shaping our clinical care.
Implementing systematic PRO data collection was a big step. Integrating PROs into the workflow so that the clinical team reviews and acts upon PRO data is phase II, which we are still in and where we have some opportunities to improve PRO visibility in the electronic medical record. For me, phase III is the most exciting part, where we can contribute to research such as predictive tools based on baseline or early treatment PROs that identify high-risk populations for early intervention, how specific interventions or adaptations in response to PROs can improve outcomes, and how PROs may be improved with different treatment modalities or approaches. That’s certainly the end game, to use this data to make tangible improvements in patient care. We recently completed one of our first research projects where we were able to identify a meaningful improvement in PROs with a specific intervention, and that was an exciting thing to see.
At the end of the day, I believe in PROs because they capture and preserve the voice of the patient in data analysis and decision making. When we think about the individuals we care for, very little of their lived experience with cancer is captured using other data elements. PROs can distill the complexity of the patient experience–that personal narrative usually confined to the “subjective” portion of a note–into discrete data elements. With a transition to value-based healthcare, if we are lacking data on the patient’s lived experience, it seems far less likely that care transformation models will fully appreciate the impact on quality of life and what really matters to patients.The views, information and opinions expressed in this interview are those of the speakers and do not necessarily represent those of Brainlab.