Value-Based Care Basics
History, Measurement types and Important players
Intro
This is meant to be a high-level primer on value-based care (VBC). As usual, I try to cover the basics and link out to more detailed sources for those who want to go deep.
This time, I want to give a special shout out to the Value-Based Care course from Humana and University of Houston, which gave a really good outline and introduction to other resources for me, plus a few good visuals which I have used below.
The beginning of the journey for me came from understanding how VBC literature links a few important words in a logical chain intended to bring value to the patient.
Value, Quality, Outcomes, Evidence
There are a lot of linked terms that are important to understanding the basis of value-based care.
You’ll see these terms a lot throughout this post, so I wanted to quickly outline what is meant by each of them and how they are related.
Value
Used in the standard oxford dictionary way of “the regard that something is held to deserve; the importance, worth, or usefulness of something.”
Basically it means that care should be useful to patients.
Quality
After having established that they are trying to give patients something valuable, the VBC literature often makes the logical jump to talking about quality.
Quality in the usual business sense is how good something is compared to an objective standard or other similar products or services.
In the case of VBC, folks tend to define clinical quality standards in reference to outcomes. See the definitions from various clinical non-profits here:
Outcomes
Basically means that patients should get better from their care, or at least that they get worse more slowly.
Good outcomes are incentivized in VBC by trying to prevent the worst outcomes: prevent really bad diseases like heart disease or cancer, keeping chronic conditions well managed, and keeping the patient out of the hospital.
Good outcomes are rewarded by sharing savings with a doctor who keeps a patient out of a hospital with any of those bad outcomes.
Evidence
Theoretical good outcomes are often also incentivized with regards to ‘evidenced-based’ practices, ie. practices that have been demonstrated in studies to reduce bad outcomes.
This is why there might be incentives for cancer-screening, blood pressure tests, labs, etc. In studies these screenings have led to better outcomes.
Origins and Foundational Concepts
Shifting gears, I wanted to do a quick nod to the origins of the VBC movement, which I think (others can correct me( can be roughly traced to a report called ‘Crossing the Quality Chasm’ by the Institute of Medicine, published in 2001.
The report recommended large scale reforms to the health care system. Here, I’ll quote from the excerpt which spells out its aims:
Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers:
A set of performance expectations for the 21st century health care system.
A set of 10 new rules to guide patient-clinician relationships.
A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality.
Key steps to promote evidence-based practice and strengthen clinical information systems.
Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Among the recommendations was the assertion that care should meet six aims STEEEP:
Safe
Timely
Equitable
Effective
Efficient
Patient-centered
The Triple Aim
The next key concept for value based care came in 2008 in a paper for the Institute for Health Improvement (IHI) in a paper by Don Berwick, Tom Nolan and John Whittington. It outlined the ‘Triple Aim’ of health care:
Improving the patient experience of care
Improving the health of populations
Reducing the per capita cost of health care.
You can see more about that on the IHI’s site.
Transition in care
From these two documents and others like it, we get the recommendation to transition care from ‘episodic’ (getting treatment for acute issues when needed) to ‘population-focused’
Population-focused
What is population-focused care? Basically it’s the foundation of the discipline of ‘Population Health’, which we’ll cover more in a separate post. It recommends:
Segmenting patients into three risk categories: high, medium, and low
Focus high-impact care priorities that yield the most value for each segment
For lower risk patients, access becomes more virtual and convenient, freeing up resources for higher risk patients
For high risk patients, use more resources to help them effectively manage their health and conditions
Quality Measures
To achieve high-quality health care, we need to measure quality in some way. There are two main categories of quality measures: Process and Quality.
I’m going to sketch out what is meant by each of these. After that, under the ‘Standard Measures’ section, I’ll link these to organizations and systems that create and administer these measures.
Process measures:
These measure whether certain services are provided to patients that help monitor or improve their health.
These are usually ‘evidence-based’ good-practice recommendations. They are things like:
Blood Pressure measurement
Mammograms
Colon cancer screening
Labs
etc.
The majority of reported measures are process measures because they are in many ways easier for the healthcare system to gather data on, and we’ve been gathering them for longer (since before there was an increased focus on outcomes) and you’ll see this reflected in the number of standards and organizations that administer them under the ‘Standards’ section below.
Outcome measures:
These are the real goal of VBC. They answer the question: did a patients health status improve.
They are measurements like
Surgical mortality
Hospital acquired infection rate
Hospitalization rates
etc.
Quality of care was traditionally measured by whether doctors did what was generally considered best practice, not outcomes.
The VBC movement wants to change that to improve outcomes cost-effectively.
Some types of outcome measures
CMS has 7 categories of outcome measures, each of which has specific measures underneath, which are spelled out on their website.
The categories are:
Mortality
Readmissions
Safety of care
Effectiveness of care
Patient Experience
Timeliness of care
Efficient use of medical imaging
Patients play a role in reporting some of these outcomes, so I’ll cover the tools for gathering that data from patients briefly.
PROM - Patient Reported Outcome Measures
PROMs are measures that are build on Patient Reported Outcomes (PROs). These are usually gathered by short surveys. Examples include:
health-related quality of life (including functional status)
symptoms and symptom burden (e.g., pain, fatigue)
health behaviors (e.g., smoking, diet, exercise)
Or specific performance measures after an intervention such as:
Back Pain After Lumbar Discectomy/Laminotomy (CMIT Family ID 85)
Functional Status After Total Knee Replacement Surgery (CMIT Family ID 279)
PREM - Patient Reported Experience Measures
Patient-reported experience measures capture a patient’s experience of receiving care, specifically the patient’s perception of what happened during their care encounter and how it happened.
They could capture data on:
Timeliness of communication
Access to appropriate providers
Whether the patient’s concerns were addressed
Does the patient feel like they are getting better
Measurement best practices
There has been a shift towards outcome measures (as opposed to process measures) for clinical and financial outcomes.
Over time, it was found that linking outcomes to process are easier when:
The patient group is well-defined by a medical condition or demographic characteristics
When there is a well-accepted physiologic, biochemical or psychological mechanism that links a medical intervention with an outcome
When the outcomes are targeted for the medical condition
Examples of tying processes to outcomes for these specific categories can be found on the specific diagnosis related measures outlined by:
Standard Measures
Standard Outcome Measures
Outcome measure standardization is driven mainly by two organizations:
The National Quality Forum (NQF), a non-profit for measurement and quality reporting outcomes with a focus on safety and quality
The Center for Medicare and Medicaid Services (CMS), the government agency that administers Medicare and Medicaid.
NQF tools
NQF Quality Positioning System - for searching for specific quality measures
Patient Experience measures surveys:
CMS and CMS-sponsored tools
All managed care organizations paid my medicare have to use a set of common quality measures and surveys
CMIT - CMS measurement inventory: a tool for searching all of CMS’s measures
Patient Reported Outcomes & experience measures
CMS Star Ratings
CMS uses these measures to administer their Star Ratings Program. Here are a couple visuals outlining the principles of that program. I hope to go into this in more depth in a future post
Standard Process Measures
There are a number of bodies that do process quality measures for the healthcare system. One problem is that there isn’t much standardization amongst them. The most important ones, as far as I can gather are the Medicare and Medicaid programs and the NCQA programs below, and so I’ve covered them in a bit more detail.
Medicare
Medicare administers some programs that incentivize evidenced-based quality processes that are intended to drive better outcomes. The organization that’s responsible for this at Medicare is the Quality Payment program
QPP - Quality Payment Program
The Quality Payment Program includes a couple ways to incentivize providers to improve quality as alternatives or complements to the Fee-for-service payments they receive. I’ll mention some of these programs here:
Merit-Based Incentive Payment System (MIPS)
Through the MIPS, providers can earn performance-based payment adjustments for services to Medicare patients
Alternative Payment models - (APM)
Alternative payment models provide alternative ways to get paid based on
customized approach to payment developed by CMS, designed to provide incentives for high quality, high value care. APMs can focus on specific conditions, care episodes, or populations.
The APMs include the core measure sets below:
Core Quality Measures Collaborative Core Measures Sets
The Core Quality Measures Core Measure Sets are listed on the Quality Forum site, and fall into the following categories:
Medicaid
For Medicaid there are two core sets of quality measures, one for children and one for adults:
The adult core set includes two dozen or so measures in the following categories:
Primary Care Access and Preventative Care (includes cancer screenings)
Maternal and Perinatal Health
Care of Acute and Chronic Conditions
Behavioral Health Care
Experience of Care
Long-term Services and Supports
Child Core Set ( Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP)
The Child Core Set includes all the same categories as the Adult Core Set (though the measures are different in many cases), and also includes Dental and Oral Health Services
NCQA - National Committee for Quality Assurance
The National Committee for Quality Assurance is a non-profit organization dedicated to measuring quality and improving health care, including providers not paid by Medicare or medicaid.
They highlight top performers and measures and assess health plans’ quality programs.
They work with Federal and State governments to run their programs.
HEDIS - Healthcare Effectiveness Data and Information Set
HEDIS is a set of 81 clinically centric measures.Health plans require providers to report on HEDIS measures.
HEDIS measures fall into six domains:
Effectiveness of care
Access and availability of care
Experience of care
Utilization and risk adjusted utilization
Health plan descriptive information
Measures collected using electronic clinical data systems
There are other sets of quality measures and accreditations (which I’ll go into below), but anecdotally, HEDIS is by far the most common reference for non- CMS quality measures.
URAC - Utilization Review Accreditation Commission
URAC is another independent non-profit , mission to advance healthcare quality through accreditation measurement and innovation
They rune 28 accreditation programs for health plans, health care management, health care operations, pharmacy quality management, provider integration and coordination, mental health, substance use disorder, telehealth, contact customer call centers and more.
AHRQ - Agency for Healthcare Research and Quality
Federal agency in charge of researching safety and quality of American health care system.
They have some standards and fund research and quality products and tools
The Joint Commission
The Joint Commission is another non-profit accreditation body that’s been around since 1950.
22000 orgs accredited, including labs, hospitals, nursing care, cardiac and stroke, healthcare staffing services.
Wrap up
Ok, so that was a lot! There is a lot going on in VBC measurement and administration. That said, I provided relatively little detail about each part of the ecosystem. You can click all the links and go down your own rabbit hole if you want to fill in the gaps.
In future posts, I want to cover the more practical details of implementing value-based care systems for health tech practitioners. Watch this space!
Other Resources:
IHI site Triple Aim
https://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx#:~:text=It%20is%20IHI's%20belief%20that,capita%20cost%20of%20health%20care.
PROMs & PREMs:
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2790756
CMS outcomes measures:
https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/outcomemeasures
National Committee for Quality Assurance. (2015). Exploring the Past and Future of Health Care Quality.
Wright, J. (2015). Six Dimensions of Healthcare Quality.
Institute for Healthcare Improvement. (2008). Defining Quality: Aiming for a Better Health Care System.
Quality Measures AHRQ Patient Safety. (2019). Reasons to Choose a CAHPS Survey.
This 1-minute animated video helps healthcare administrators, clinicians, and staff who are interested in gathering information about their patients’ experiences with care understand the key benefits of using the CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys, developed by the U.S. Agency for Healthcare Research and Quality (AHRQ). National Pharmaceutical Council. (2014). Health Care Quality Measures in Accountable Care Systems: Why They Matter.
National Pharmaceutical Council. (2014). PROM Examples. http://patientreportedoutcomes.ca/what-are-pros/prom-examples/