The notion of value-based care certainly is not a new one. But the concept of what it involves within the health care system and how it can be measured is undergoing a shift, asserted two industry experts. Life sciences companies in particular have an important role to play to ensure that quality and equity in health care are truly achieved.
A value-based care approach “is not centered around a certain payment model or a certain program demonstration,” maintained Taylor Musser, associate principal in the healthcare transformation practice at Avalere Health. Rather, it’s focused on ways to improve the quality of care, she told attendees at a recent webinar sponsored by Avalere. Such an approach will “encompass what care could be delivered by a provider or health system or the care that is coordinated by health plans. And some of the quality objectives” include “are we getting the clinical outcomes we want, are we improving people’s general quality of life and what they experience day to day, [and do] the services or processes of care…align with clinical practice guidelines, for example? We know there are gaps there.” She stated that “avoiding inappropriate or low-value services…is still a concern in our health care systems.”
“What’s foundational to all of this is really centering it on the person” — and not only patients’ goals but also those of their caregivers, families and friends — “and doing that through things like shared decision making and making sure that the care that we deliver aligns with what the person wants,” she asserted.
This may be easier said than done, though. “This is a little bit of a transformative shift for our system because we’re fixated on the near-term service use or volume of care, and now we’re talking about things that have long-term benefits. For example, when we screen for cancer earlier or diagnose a disease sooner or just promote healthy behaviors like good diet or physical exercise, these are all things that have downstream impact on outcomes that are not immediately realized. We need to kind of widen our aperture and think about the longer-term vision. So I think quality is kind of that long gain that we need to think about in value-based care.”
Asked by moderator Elizabeth Carpenter, general manager and head of advisory services at Avalere, where the next phase of the quality conversation is likely to go, Tricia Marine Barrett, executive director of quality and population health strategy at Bayer Pharmaceuticals, replied, “I know we’re going to talk about health disparities, health equity.” She pointed to the 2001 Institute of Medicine Crossing the Quality Chasm Report, which “defined quality along six dimensions, one of which was equity — that care is equitable, that it’s accessible and efficient and is being delivered in ways that meet the patient’s needs. So it’s nice to call it a revolution as we think about quality in these new ways, but really, it’s just a continued drumbeat, an evolution of our thinking and the sophistication of the quality measurement itself to enable us to really understand whether quality is meeting those lofty objectives, those goals of being something that is attentive to the individual’s needs and preferences and that that care is bringing value to the health care system.”
She pointed to an “important shift” that’s been happening within the health care system: “the pairing of and understanding of what is value, what is quality, what is the value of care that’s being delivered with payment models that help to make sure that that care is feasible in our health care system?” This, she stressed, is “not something that…when you apply pressure in one place, you’re going to have that balloon pop out in another place. We need to make sure that all of the unintended consequences of payment models, that the approaches that are taken to measurement are keeping an eye on the whole patient journey, the whole view of that patient’s needs and not shortchanging in favor of short-term gains, short-term outcomes. And so [it’s] really important to think these things through and understand the environment that we’re working in in order to ensure that as a life science representative, that we’re bringing products to the market that can fulfill a need that people have and bring value to the various players in our health care system.”
When considering quality measures, people often “think about measures as one piece of the puzzle — like measures are used to evaluate performance, that’s what most people fix on, is that accountability and connecting payment to performance,” Musser said. Instead, she asserted, “I think we should view measures as tools that really leverage data into insights. And so I really like to talk about things like the learning health system and measures of support across that because measurement is our tools to drive evidence generation, which is critical for life science organizations and for advancing our standards of care, like clinical guidelines. Measurement is critical to providers when they’re delivering services at the point of care, making sure they’re doing the right thing at the right time for the right person, and having that data presented to them in a meaningful way through measures is powerful for doing action. And then of course at the end of the cycle, that accountability piece: Overall, if we look back at you, how was your performance generally? So I would really like to shift the measurement conversation from accountability to how do we do improvement, how do we drive our actions, and how do we continually advance what we know about clinical practice guidelines and standards of care?”
Barrett agreed. “We need to make sure that we think about that balloon and think about where we’re applying pressure and how specific measures or specific approaches might impact and have unintended consequences,” she suggested. That would allow for a “robust and complete picture of what’s happening with performance that takes all these dimensions into account and doesn’t have these unintended consequences that traditionally have existed and will always exist, and we just need to be mindful of them.”
But measuring some aspects may prove to be a challenge. For instance, health equity “has always been a central tenet of quality; it’s been there for the last 25 years. But I think we’re starting to figure out that it’s underrepresented in how we approach measurement,” said Musser. “So I think what we’re seeing of late is trying to figure out how do we do health equity measurement, and there are several approaches that are being explored. We’re talking about drilling down into measures through things like stratification to shine a light on disparities in terms of outcomes and disease burden. We’re talking about including things like social determinants of health, whether that’s through focusing on those aspects through stratification or even developing new measures that try to incentivize identification of some of those social risks, social needs and social determinants. And then start to push the system into acting on those or considering those and how they interact with clinical outcomes.”
According to Musser, “I think we’re trying to figure out what tools are available and where should they go because…there are unintended consequences to measures. There’s a saying: What gets measured gets done. That’s why I think people are trying to be very careful about how they approach this because it’s a problem in the system, data is critical to understanding it, but we want the right action to happen.”
Barrett told attendees that she is “optimistic and enthusiastic about this opportunity to really have the stratification of performance measures in ways that allow us to shine that light on the inequities that do exist today. Although it’s always been part of the concept of quality, it’s not always been part of the actualizing of it, certainly as it relates to…being tied to incentives and so forth. The role of every player in the health care system — but, certainly life sciences, Bayer — in the issue of health equity is to have that awareness of the issues that exist, the longstanding, systemic barriers to care that have been present. When thinking through, even from the beginning…of a chemical compound that’s going to somehow change people’s lives is to not simply look at the total impact but to think about the impact on specific populations.”
For instance, she said, “we’re working in chronic kidney disease and the importance of kidney disease and the way that care is delivered for kidney patients today and how it’s different for different populations.” This, contended Barrett, “really needs to play into how do you then measure the effectiveness of the drug itself and of the systems of care through which that drug or other care might be delivered to a patient so that you’re getting equitable outcomes in the endpoint?” It’s important, she stated, that as companies are designing clinical trials, that they are ensuring diversity exists in those trials “and all the way through to the execution and availability and access of a treatment within an admittedly flawed health care system.”
Ultimately, said Musser, “I think when we’re talking about health equity and quality, value-based care, I think people should be thinking about it throughout the product lifecycle, whether that’s establishing the evidence base to be sure people are equitably represented [or] making sure the outcomes are equitably evaluated. The other piece is life sciences companies are uniquely positioned. They know the population, they know the disease states, they know the barriers to treatment, and I think they’re in a really great position to work in partnership — whether that’s with policy makers, the delivery system, payers — to be advocates, to provide resources and to think about solutions to the problem in the admittedly flawed health care system that we have.
“So I think that this is an issue where there’s lots of opportunity for us to come together as a community and to really advance the quality of care and do it throughout drug development and when it’s being launched into the market to really achieve that triple aim of improving the health of a person, population health and addressing the ungodly costs that we see in our health care system.”
Barrett maintained that she’s optimistic about the quality conversation that the industry is undergoing “because it seems sustained. The discussions that we’ve been having…have really blossomed in the sad light of COVID into something that seems more of a sustained direction toward and focus on health disparities. There’s more action being taken than I’ve seen in the 30 years that I’ve been doing health care quality work. So that gives me hope.”