June 2014, Vol 3, No 4

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Personalizing Value-Based Medicine

Aymen Elfiky, MD, PhD

Value-Based Cancer Care

The multidimensionality of health for an individual is best captured by the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1 With respect to oncology, sophisticated advances in molecular biology and technology continue to better facilitate the management of cancer as a chronic, albeit complex, health condition. Nonetheless, for early-stage and terminally ill cancer patients alike, extended longevity has also prompted a growing focus on the parallel dimensions of heath included above. As cancer is the second leading cause of death in the United States,2 cancer care delivery is consistently at the center of debates over the affordability of healthcare. The continually rising costs, ironically effected in part by progress of new expensive diagnostic and therapeutic paradigms, have increasingly been impacting health systems across the country. It is within this continually evolving cancer care landscape that the concept of value-based care has been taking center stage.

To date, the pursuit of value, defined as patient outcomes per dollar spent,3 has been characterized by various management and policy efforts that aim to reduce medical errors, minimize practice variation through use of clinical guidelines, and facilitate information exchange between providers. Not surprisingly, despite the providers and institutional leaders who define and ultimately operationalize care delivery, this compliance-based approach to delivery of value-based care has not consistently translated to institutional cost containment or patient outcome benefits. A clinical process-based view of cancer care delivery helps to shed light on the shortcomings of this approach. Specifically, viewing care delivery organizations as complex adaptive systems4-6 with networked stakeholders that typify the practice and delivery of cancer care, a value-based approach must fundamentally eschew the rigid machine-like view to instead account for the perspectives and interdependent roles of the institution, provider, patient, and payer. This restructured systems view is of paramount importance to cancer care given the technology-driven and -enabled role of the patient and caregiver.

The quest for value within cancer care can be seen as prompting a return to the fundamentals of what is “health” and what is the mission of any healthcare organization that purports to achieve it. Within a complex adaptive system, cancer care necessarily must account for patients and caregivers as individual agents in pursuit of parallel dimensions of health, whose needs are networked with the series of interventions enabled by organizations, implemented by providers, and reimbursed by payers. In a system anchored by the care of cancer patients, “health” is enabled by a range of interventions such as curative surgery, palliative chemotherapy, access to novel trials, and survivorship care. Thus, the need of individual patients varies depending on where they are in their disease pathway and trajectory. As such, the patients’ health state provides the context for the other system agents and requires them to coevolve to achieve health outcomes. As reasoned by Porter, “since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge.”3 Successful commitment to achieving value centered on quality of care from the patient’s point of view requires a nimble system willing and capable of adapting and re-engineering practice processes.

Building on the above point of outcome measurement, the next issue becomes defining and capturing specific patient-derived outcomes within clinical scenarios. Considering the spectrum of care and outcome issues from localized to advanced cancer states, it is clear that certain outcomes become prioritized relative to others based on disease and patient characteristics. Considering prostate cancer as an example, the quality-of-life metrics that characterize patients with localized disease may include degree of incontinence and erectile dysfunction. In contrast, patients with advanced-stage disease are invariably concerned with outcomes of survival, pain control, and toxicity management of systemic treatments that they may be receiving. For any given institution or practice to successfully capture and accommodate these varying needs depends on baseline conditions, the adaptive reserve, and the cultural view toward personal and organizational change.7 In most practices, however, there is no consensus or existing infrastructure for consistent capture of patient-specific outcomes. In the same vein, payers do not have any requirements for such outcome measurements. Ultimately, this lack of definition and capture acts as a barrier to incentivize preferred practices. Importantly, given that many point-of-care decisions by providers, especially when dealing with advanced cancer patients, are based on patient-defined considerations, the value of these decisions is not often captured in their compliance or lack thereof with guidelines or pathways, but instead the specific patient outcome for which each decision was undertaken. By extension, consistent evaluation of outcomes then provides a backdrop against which to assess cost utilization, which defines value.3,8

A useful framework to characterize outcomes of relevance to patients for any given medical condition, including specific cancer diagnoses, is to use the 3-tiered “outcome hierarchy” defined by Porter and Teisberg9:

  • Tier 1 involves the health status achieved, eg, performance status, pain levels, and mortality
  • Tier 2 outcomes relate to the care cycle and processes, eg, hospital readmission
  • Tier 3 outcomes relate to the sustainability of health, eg, psychosocial services for survivorship

An example that helps to illustrate the use and impact of outcome measures in healthcare practice is the Integrated Healthcare Association’s overseeing of the California Pay-for-Performance (P4P) plan. It is a large physician-incentive program representing 8 health plans representing 10 million insured people.10 Operationally, the program collects data on a common measure set that captures practice outcomes of about 35,000 physicians in 221 practices.11 The success of the program was reflected in 87% of clinics improving their ratings by an average of 5.3% and a 65% improvement in patient experience. In contrast to existing fee-for-service systems, which do not integrate quality of care, the P4P program highlighted the incremental cost benefits realized when patients’ outcomes were shown to be improving.12 Notably, a similar attempt in the United Kingdom using the Quality and Outcomes Framework did not show a similar benefit precisely because cases were being inadequately related to patients’ outcomes.13 This account offers a cautionary lesson that achieving value using outcomes-based measures requires a proper infrastructure to collect and analyze outcomes. Fundamentally, these outcomes are normalized to reflect the differences and nuances of a particular specialty as well as the patient populations in each specialty. Naturally, care offered to advanced-stage cancer patients is more complex; however, this complexity underscores the opportunity for impact across the various outcome tiers above.

Given the discussion points above, the action point that will naturally facilitate the migration toward value-­based oncology practice is to equip practices with an infrastructure designed to capture standardized and structured data reflecting disease-specific outcomes. The variables used should be a natural reflection of patients’ goals of care viewed within the context of their physical, mental, and social condition. Ultimately, the individual and collective findings can be used to drive performance improvement and transparency. Insomuch that an outcomes-focused infrastructure represents an innovation at multiple levels, its adoption is driven by institutional culture and reflected at point of service. This adoption, in turn, reaffirms true dedication to the patient writ large.

1. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
2. Siegel R, Ma J, Zou Z, et al. Cancer statistics, 2014. CA Cancer J Clin. 2014;64:9-29.
3. Porter ME. What is value in healthcare? N Engl J Med. 2010;363:2477-2481.
4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2000.
5. Plsek PE, Greenhalgh T. The challenge of complexity in health care. BMJ. 2001;323:625-628.
6. Sweeney K, Griffiths F, eds. Complexity and Healthcare: An Introduction. London: Radcliffe Medical Press; 2002.
7. Nutting PA, Crabtree BF, Miller WL, et al. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med. 2010;8(suppl 1):S45-S56.
8. Porter ME. Defining and introducing value in health care. In: Evidence-Based Medicine and the Changing Nature of Health Care: 2007 IOM Annual Meeting Summary. Washington, DC: National Academies Press; 2008:161-172.
9. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston, MA: Harvard Business School Press; 2006:86-87.
10. Integrated Healthcare Association. Pay for Performance. www.iha.org/perfor mance_measurement.html. Accessed April 30, 2014.
11. Ezziane Z. Pathways and complexity of innovation in health care. http://pub.bsalut.net/jhiic/vol3/iss1/2/. Accessed April 30, 2014.
12. Maynard A. The powers and pitfalls of payment for performance. Health Econ. 2012;21:3-12.
13. Fleetcroft R, Cookson R. Do the incentive payments in the new NHS contract for primary care reflect likely population health gains? J Health Serv Res Policy. 2006;11:27-31.

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