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Making APMs Truly Value-Based Through Person-Centered Care
Alternative payment models do not truly incent value-based care unless providers are accountable for delivering person-centered care, an industry expert says.
Each stakeholder brings their own definition of value to the table when developing alternative payment models, which incent providers through value-based payments to deliver care that aligns with the agreed-upon definition of value.
Regardless of who is defining value in alternative payment models, each stakeholder should consider and assess how value is perceived by those at the center of care: patients and their caregivers.
That is the bottom line for Rebecca Kirch, JD, executive vice president of healthcare quality and value at the National Patient Advocate Foundation.
“If you don't get feedback early on about what really matters or what the value equation is for patients and their families, then we're just stabbing in the dark in terms of quality measurement and the associated payment reforms that are so-called ‘value-based,’” she recently told RevCycleIntelligence.com. “The question becomes: What's convenient for the healthcare professional, the health system, or the payers? Instead of: How do we drive home person-centered care?”
Patient-centered care, and to a lesser extent person-centered care, is a staple of value-based payment reform, and many alternative payments models include quality measures that assess patient-centered care through metrics for care coordination, patient engagement, and patient satisfaction.
For example, some models rely on the Consumer Assessment of Healthcare Processes and Services, or CAHPS, survey to measure patient satisfaction and experience. Other models use patient-reported outcome measures, which involve data coming directly from the patient without the interoperation of a patient’s response by a clinician or any other stakeholder.
The quality measures around patient-centered care are a step forward – albeit rarely used in the case of patient-reported outcomes – but they don’t target the heart of the issue, which is measuring the value of care according to the patient and their families.
“It's like the context of shared decision making with physicians where they say, ‘Sure. We did shared decision making. I made a decision and I shared it with the patient.’ That's not what the intention of truly person-centered care is,” Kirch said.
“From the beginning of a clinical encounter, you should be saying to people, ‘Tell me what your understanding is about your current situation and how you'd like to get medical information. Let's talk about what's important to you in the construct of what you're experiencing.’ If we don't ask that first for everybody, no matter what their diagnosis is, we're never going to identify what outcomes we should be using to measure success,” she continued.
Getting patients involved in the alternative payment model development process will help payers and providers advance value-based care that is truly high-quality, person-centered, and ultimately meaningful to the patient.
Engaging patients in APM development
Guides on how to develop alternative payment models typically emphasize the role of clinician or leadership engagement, the selection of an appropriate disease or population, and the establishment of quality measures that can be reported by providers and assess meaningful outcomes.
The guides, like the one put forth by the American Medical Association, mention patients, advising providers and payers to consider the impact an alternative payment model may have on patient outcomes, costs, and satisfaction.
But getting the patient involved in the development process rarely makes the steps payers and providers should take when creating an alternative payment model.
Some organizations, like the Patient-Centered Outcomes Research Institute, are rectifying the issue by using real patients or patient advocates in an advisory capacity for decision-making. However, many stakeholders following in their footsteps are not taking it far enough, Kirch explained.
“What has happened lately is that patients were included but it was a single patient,” she said. “And they become professional advocates who are involved again and again, and they say the same thing again and again depending on their perspective. That’s not representative of all patients.”
Payers, providers, and other organizations responsible for anything that impacts patient care need to involve multiple individuals and/or patient advocates when developing an alternative payment model, medical device, prescription drug, or any other healthcare service, she contended.
And the organizations need to incorporate patient feedback into the development process to develop alternative payment models that incent high-quality care.
"What has been increasingly recognized but hasn't been formalized yet is the importance of patient expertise, or what they bring to the table about their own makeup. It's as important as any clinical expertise a clinician has," she said. "Patient can tell us what's important to them in terms of making a treatment plan and aligning treatments with particular preferences and priorities."
"If you don't know those things, you can't deliver person-centered care and it certainly can't be considered quality care," she highlighted.
With patients telling payers and providers what is valuable to them, alternative payment models can start to include quality measures that assess value-based care for all.
Creating quality measures to incent person-centered care
Based on input from patients and their caregivers, alternative payment models should include skilled communication quality measures to measure value-based and person-centered care, Kirch advised.
“We can create all sorts of quality measures that could matter to patients, but if clinicians haven't received the training on how to talk to people with compassion instead of merely fact-based transactional language it won’t matter,” she explained.
Clinicians and other stakeholders need to start going beyond clinical speak to engage patients.
“We’ve become so conditioned – to the point where even patients do this now – to only talk about conditions. But we're missing half of the clinical data that we need to make value-based decisions,” she stressed.
Creating quality measures around skilled communication will provide the carrot and stick lacking from traditional alternative payment models, incenting healthcare organizations to invest in skilled communication training and providers to better connect with patients to provide high-quality and even lower-cost care, Kirch stated.
“You can know everything about every chemotherapy agent or combinations of therapy. But when you're looking at the return on investment, you're just rattling off those names to patients and they are hearing the Peanut's parents noise. They've just been presented with a fact-based clinical conversation when they are reeling inside with emotion, which has not been addressed,” she said.
Clinicians will oftentimes resist adding another quality reporting component to care delivery. Physicians alone spend about 2.6 hours a week on quality reporting, which could translate to nine additional patient encounters, research shows.
But in a value-based world, employing skilled communication is a necessary for achieving the goals of alternative payment models, Kirch emphasized.
“You're wasting your time anyway because patients haven’t heard a word you're saying. So, you're not delivering good quality care,” she said.
