Cancer is a high-priority target for value-based care. Innovations like immunotherapy are transforming oncology and lengthening survival, but they carry an exorbitant price tag; the average annual price of a cancer drug rose from less than $10,000 per year before 2000 to $170,000 per year in 2017. To ensure that high-quality outcomes are obtained from cancer care expenditures, we need value-based solutions and the right measures to assess value.
But what is value in cancer care, and how do we measure it? In health care generally, “value” is usually defined as the quality of health outcomes achieved compared to the economic cost. Cancer presents complex challenges for both the quality and cost aspects of value. Furthermore, patients, oncologists, payers, industry, and health care purchasers all have unique perspectives about what is valuable. While oncologists typically emphasize the need to select the right treatment for the right patient, payers often focus on the scale of the clinical benefit compared to the price. From the patient’s perspective, the most valuable outcome of care might be whether they can to go to the grocery store or their grandchild’s wedding. As we move from volume- to value-based care, meaningful quality and cost measures help bridge the various perceptions of value to create a common understanding.
This first blog installment is an introduction to our blog series titled “Quality Outlook,” which will examine current issues in cancer quality, gaps in oncology measures, and solutions for improving cancer care value.
Venturing Toward Value
Public and private payers are accelerating adoption of value-based payment models. While the Centers for Medicare & Medicaid Services (CMS) has generally taken the lead in transforming payment, commercial payers kickstarted cancer value by testing innovative bundled payment initiatives. For Medicare payment under the Merit-Based Incentive Payment System (MIPS), CMS requires physicians (including oncologists) to report quality and cost performance data to avoid negative payment adjustments. Under another option, physicians can earn Medicare payment bonuses for participating in alternative payment models (APMs), such as the Oncology Care Model. Most recently, CMS proposed a new episode-based radiation oncology APM that will be mandatory for certain radiation therapy providers.
In value-based payment models, cost containment incentives must be counterbalanced by quality measures to ensure that patients are not denied access to appropriate yet potentially costly care. Quality measures are tools that quantify processes, outcomes, patient perceptions, and structures or systems that are associated with a spectrum of goals for health care, such as safety, effectiveness, and timeliness.
While many cancer quality measures exist, measures are needed that are more meaningful and actionable to support care improvement and not just document processes. While capturing new data for value-based programs has increased awareness about opportunities for clinical improvement, angst abounds about the burden of collecting and reporting mounds of measurement data (OCM Stakeholder Public Forum: Discussion Highlights & Summary. June 14, 2017).
What’s Missing From Cancer Quality Measurement?
Oncologists, payers, quality experts, and others have pursued improvements in cancer quality measurement for years. However, many challenges remain, including patient attribution to clinicians, complex risk adjustment for outcomes, small sample sizes affecting reliability, and gaps in evidence. Despite CMS’ prioritization of cross-cutting outcome measures, most of the oncology quality measures currently available still focus on cancer screening, care initiation, or symptom assessment for only the most prevalent cancers. ASCO’s Quality Oncology Practice Initiative (QOPI) includes hundreds of quality measures, but only a few measures focus on outcomes (ie, utilization of resources at the end of life). There are many opportunities to fill gaps by developing measures that assess important aspects of care, such as care planning, diagnostic accuracy, and patient-reported outcomes.
These measure gaps extend to accountability programs. For example, in the oncology specialty measure set for MIPS, 21 of the 24 measures are process measures. Patient-reported measures that move beyond experience surveys are of particular interest, and though some progress has been made—the Oncology Nursing Society added a patient-reported health-related quality-of-life measure to its quality improvement registry in 2019—no major CMS program is requiring oncologists to report performance on these extremely important yet potentially burdensome measures that capture the patient voice. Measures of ultimate clinical outcomes (ie, cancer recurrence and survival) are still elusive because of limited data and questions about their utility for accountability, such as how to compare survival across care settings and how to risk adjust measures.
Where Are We Headed?
More work is needed to fill gaps in cancer quality measurement to meaningfully and accurately assess care value. This Quality Outlook blog series will dig into key oncology quality and value issues and explore solutions for overcoming barriers to quality measurement and improvement. Potential topics include:
- Bridging the gap in “value” definitions among cancer patients, oncologists, payers, and other stakeholders in health care, and what that means for measurement and payment
- Identifying ways for measurement to catch up with continuously evolving clinical evidence and guidelines
- Exploring the promise of patient-centered care models: what is driving transformation, how do patient preferences play a role in decision-making, and what role do patient-reported outcomes play in performance measurement
- Evaluating decision-making incentives and tools (ie, clinical decision support and clinical pathways) for influencing care
- Assessing the importance and challenges of measuring areas of treatment outside the diagnostic and initial treatment trajectory, such as palliative care and survivorship
- Understanding what quality improvement and value-based care delivery looks like on the front lines, and what we can expect in the future from APMs like the OCM and the radiation oncology model
Through the Quality Outlook blog series, we will propose forward-thinking solutions for the next generation of oncology quality measures to support high-value cancer care.
About the Quality Outlook Commentary Series
Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Discern Health will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.
About Tom Valuck, MD, JD
Tom Valuck is a Partner at Discern Health. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace.
About David Blaisdell
David Blaisdell, a Director at Discern Health, leads and manages client projects, providing insight and subject matter expertise, particularly on quality landscape analyses and measure gap identification. David has led and contributed to projects focused on oncology quality measurement to identify key gaps in measures used in accountability programs and opportunities for measure development. Through this experience, David helps clients navigate measurement and value-based payments and define strategies for success.
About Manasi A Tirodkar, PhD, MS
Manasi A Tirodkar is a Director at Discern Health. She brings a wealth of knowledge and experience in health services research, quality measurement, and practice transformation in primary and specialty care settings. Prior to joining Discern, Manasi was a Lead Research Scientist at the National Committee for Quality Assurance (NCQA) for more than 10 years. At NCQA, she led measure development projects spanning various disease conditions and populations, including oncology.
About Discern Health
Discern Health is a consulting firm that works with clients across the private and public sectors to improve health and health care through quality-based payment and delivery models. These models align performance with incentives by rewarding doctors, hospitals, suppliers, and patients for working together to improve health care while lowering total costs.