Value is the ratio of quality to cost. The delivery and measurement of healthcare quality, however, is complex. “We first need to understand and define the health outcomes that are important to patients. Then we need to put into place care pathways that will lead to those outcomes, and finally we need mechanisms to measure these outcomes,” says Catherine MacLean, MD, PhD, chief value medical officer, Hospital for Special Surgery (HSS) in New York. “To really drive improvements in quality—and hence value—the collection and reporting of these outcomes needs to be incorporated into care delivery.”
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Explore This IssueMarch 2016
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Given the importance of defining value, HSS added the position of chief value medical officer in July 2015. Dr. MacLean assumed the role, and is charged with accelerating and coordinating HSS’s efforts to deliver high-value healthcare and put mechanisms into place to routinely measure and report that value.
HSS already has a long history of delivering the highest quality care for musculoskeletal diseases, which it has accomplished in part through extensive use of clinical registries that include patient-reported outcomes. In her role, Dr. MacLean is working with HSS staff to incorporate such data into clinical practice. Simultaneously, they are building care pathways that will result in efficient care delivery.
On the cost side of the equation, high quality will produce cost savings by reducing adverse events and unnecessary care. Additionally, everyone needs to be responsible stewards of all healthcare dollars by delivering high-quality care in the most cost-efficient way.
Improving Value for Rheumatology Patients
Dr. MacLean, who is a rheumatologist, says her experience in dealing with complex diseases that affect multiple organ systems and require care from across different medical and surgical specialties and sites of service gives her an appreciation of the many clinical elements that affect the quality, cost and value of healthcare.
“Rheumatologists think in terms of the treatment of a condition and understand the importance of care coordination—concepts that are key to producing high-value care,” she says. Additionally, as a rheumatologist she is familiar with the concept of patient-reported outcomes and directing treatment to align with patient preferences—which is also key to delivering high-value care.
As efforts get underway, the short-term goal is to get defined outcome measures incorporated into patients’ electronic health records and to move forward from there. “We will use disease-specific outcome measures, as well as a general health measure, that are the same for all HSS patients, regardless of underlying disease,” she says.
Michael Lockshin, MD, a rheumatologist at HSS, and Shanthini Kasturi, MD, a third-year rheumatology fellow at HSS, are working to design value measurement systems to help patients with chronic rheumatic diseases. The systems apply both to individual patients and entire rheumatic disease clinics.
For chronic illnesses, such as inflammatory autoimmune diseases, value reflects a timespan. “Its assessment requires identifying a starting point (such as a patient’s first visit to a doctor) and a measurement point (often an arbitrary time following the starting point, such as one or five years),” says Dr. Kasturi.
Determining value for autoimmune rheumatic diseases is complex because the starting point is often vague. “[The disease] may antedate the first contact with a patient by years [or] have a gradual onset, or the patient may have been initially treated elsewhere, perhaps for an incorrect diagnosis,” says Dr. Lockshin. Also, “there may be no goal-defined ending point, but instead a future time arbitrarily defined.”
The most important outcomes occur in years. A short-term goal (e.g., relieving pain with a high-dose prescription of corticosteroids) may result in an undesirable long-term outcome (e.g., osteoporosis or osteonecrosis). Patients and doctors may place different values on the different outcomes (e.g., pain relief now vs. avoidance of disability later) and must negotiate their individual priorities.
Chronic illnesses are progressive and disabling, and are not always reversible. “Until we have cures, success may mean slowing the rate of progression or achieving partial functional improvement,” Dr. Lockshin says. “Value measures may include traditional biological measures, maintenance of function, time in the hospital, social and emotional health and less cost.”
Treatment goals differ according to initial disease severity and other characteristics. “Because rheumatic diseases are heterogeneous, as we assess value, we stratify patients by initial severity,” Dr. Kasturi says. “Because socioeconomic and psychological factors greatly impact outcome, we will stratify patients along these lines as well.”
Defining Value for Different Stakeholders
At HSS, value-based healthcare is incorporated into practice by identifying and implementing clinical care pathways that lead to the best outcomes. Best is defined conjointly by several stakeholders, including patients, doctors and society. “We measure outcomes at fixed, clinically meaningful time points, both short and long term,” Dr. Lockshin says.
For patients, success is measured against outcomes predicted after stratifying patients’ initial disease severity, relevant biological markers, organ systems involved, duration of illness and psycho-social and economic context. “Sharing this information with patients enables them to make informed decisions,” Dr. Kasturi says. “We proactively define and measure meaningful patient-reported outcomes at the point of care. These include emotional and social health, as well as physical function. We note patient satisfaction with attainment of these goals.”
For clinicians, success is measured using the same outcomes as those used for patients. There is also a focus on biologic markers and function, and pathways to achieve goals. “We identify biomarker proxies and timelines for success,” Dr. Lockshin says. “To tailor therapy interventions at early dates, we monitor our adherence to best practice guidelines.”
From a society perspective, it is important to determine direct and indirect (lost productivity) cost for patients under care, distinguishing between short- and long-term outcomes. “We describe the selected value as a function of time, distinguishing between onset of illness, first encounter and other starting points,” Dr. Lockshin says. “We describe endpoints as maximally achieved goals and as intermediate points in illnesses that last decades.”
Then, they distinguish societal value from value desired solely by the patient or caregiver. “We compare and contrast these values, with the goal of having the values align,” Dr. Kasturi says. “We measure value for the different stakeholders in sequence. We have begun with patients; value judged by providers is concurrent. Societal value (i.e., dollar costs) will follow.”
Karen Appold is a medical writer in Pennsylvania.
A History of Determining Value
Value in healthcare is not a new concept. It’s always been of interest to those who pay for it. Value-driven healthcare methodologies have been in place for decades.
Faced with increasing healthcare costs and population data that suggest the U.S. fared less well on measures of health, employers started to question what they were getting for their healthcare dollars in the 1980s. A result of this push was the formation in 1990 of the National Committee for Quality Assurance (NCQA), a not-for-profit that measures the quality of care at the health plan’s level. Although these health plan quality scores were initially constructed to help employers choose health plans, these scores are now used in a variety of transparency tools for consumers, including shopping tools for Medicare Advantage and health exchange insurance policies.
Although the performance on a number of important process measures assessed by NCQA (e.g., beta blocker use after myocardial infarction and routine assessment of glycosylated hemoglobin among diabetics) and other groups has improved—likely due to measurement and reporting—there has been growing interest over the last decade to measure health outcomes, in particular patient-reported outcomes.
Although the HSS in New York is already a top-ranking institution, Catherine MacLean, MD, PhD, chief value medical officer, says there is always room to do better. “Science is constantly moving forward, and we aim to continually incorporate best treatments to improve our patients’ health,” she says. “Within this context, however, we need to be able to measure and report our value. Historically, the U.S. healthcare system has not been very good at doing this.”