The New Paradigm: Capturing Value, Improving Access, and Maximizing Outcomes

Quality measures generate vital information on outcomes and can help ensure that medications are used appropriately and effectively.

Health care in the United States is currently undergoing significant change as a value-based system is increasingly taking the place of the traditional fee-for-service approach. New care delivery and payment models, such as accountable care organizations (ACOs), patient-centered medical homes, bundled payments, and value-based insurance design, are being implemented on the premise that they can make health care more effective and efficient.

While these new models have the potential to shift our health care system from one that is fragmented and quantity-of-services—focused to one that is coordinated and encourages high-value care, a number of issues still need to be addressed before these models can reach their full potential. These key issues are exactly how pharmaceuticals fit into this new, value-based paradigm and how we assure that medications are used as appropriately and effectively as possible.

The Need for Quality Measures With Greater Breadth and Depth

A critical step for providing high-value health care is to have the appropriate quality measures in place to identify and incentivize high-quality care. Quality measures are an important way to generate information to inform patients and consumers about the care they receive and to hold health care providers accountable for the care they provide. When linked to reimbursement or provider payment, these measures have the power to change clinical practice in significant ways.

The Medicare Shared Savings Program (MSSP) for ACOs is an example of a program that requires the use of a broad range of quality measures, including those focused on patient experience, care coordination, and care process and outcomes for specific disease conditions.¹ This reflects the multidimensional approach that is necessary to capture value. Nevertheless, the program still has its limitations. For instance, the measures used by the MSSP are focused on a limited number of individual chronic conditions, such as diabetes, heart disease, and chronic obstructive pulmonary disease.

There are many other conditions, including rheumatoid arthritis (RA), for which there are no MSSP measures. Consequently, the quality of care for patients with RA, including the appropriate use of drug therapy, is not being adequately included in the value proposition. There are also challenges with measuring care quality for patients with multiple chronic conditions, a group that comprises approximately two-thirds of the Medicare population.² The overall quality of care that these patients receive may not equate to a simple summation of the individual metrics used for each disease area. The use of condition-specific measures for this population may even result in suboptimal care. These patients may need a different type of quality measure that is focused on overall function or satisfaction with care.

Incorporating Value Into Benefit Design

The value of pharmaceuticals also must be taken into consideration in the development of drug benefit designs. Facing a highly restrictive formulary or high cost-sharing may affect a patient’s ability to access effective drug therapy. Published research demonstrates the negative effect that increased out-of-pocket costs can have on adherence rates and health outcomes. For people diagnosed with multiple sclerosis (MS), for example, increases in cost sharing are associated with the delayed initiation of effective MS therapies, thus increasing the risk of disease relapse and progression.³ Patients with MS who experience disease relapse or progression may also experience additional costs resulting from hospitalization or the need for home health care. Moreover, not all patients with MS will fully recover from their disease relapse, thus leaving them worse off in terms of functional status and quality of life.

Capturing the value of pharmaceuticals and incorporating this knowledge into quality measurement and benefit design is complex and challenging. However, the alternative, a world in which the benefits of pharmaceuticals are not considered in value determinations and costs are the sole driver of benefit design, may only serve to worsen health outcomes and disincentivize the introduction of new and innovative drug therapies.

The Role of Pharmacists

In addition to the critical role of primary care physicians, specialists, and nurse practitioners, pharmacists, too, have an important place on the care team. The expanded use of medication therapy management places pharmacists in an important position to manage patients’ drug therapy and to be the nexus between patients and their prescribing physicians. Patients with multiple chronic conditions—given the risks of drug­—drug interactions and other polypharmacy issues—are a prime example of a population that benefits greatly from the work of pharmacists.

Pharmacists can have a very beneficial effect on medication adherence rates, health outcomes, patient engagement, and overall care quality. While the pharmaceutical products produced by the drug industry are a crucial component for improving health care quality, optimal use of those products can be aided by the services that pharmacists provide. As the new care delivery models continue to integrate care using team-based approaches, pharmacists can and should increasingly play a key role in efforts to ensure that patients receive optimal drug therapy and high-value care.

Moving Forward

As incentives in the health care system are realigned to reward high-value care, additional work is needed to develop measures and measure sets that can fully assess that care. Even with health information technology systems in place, there are a finite number of quality measures that can be used in any single health care system before the burden becomes unmanageable. Deciding on the measures to use and developing the infrastructure to collect performance data reliably and efficiently is an ongoing challenge for the health care community.

Many efforts are under way to meet this challenge, including projects led by the National Pharmaceutical Council (NPC). The NPC is focused on identifying gaps in quality measurement related to the treatment of patients with high-impact conditions that may be sensitive to pressure on providers to reduce costs. This project is meant to identify gaps in measures and suggest ways to address them. The development of quality measures that recognize the value of appropriately delivered drug therapy will allow the health care system to progress in a positive direction. Combined with drug benefit systems that facilitate patient access to effective, high-value care, it is possible to achieve a truly value-based health care system and our shared vision of a healthier population.

Chuck Shih, PhD, MHS, is the comparative effectiveness research (CER) policy fellow at the National Pharmaceutical Council (NPC) and The George Washington University (GWU) School of Public Health and Health Services. In his role at NPC and GWU, Dr. Shih examines the health care policy implications of CER in its use by different health care decision makers.

Before coming to NPC, Dr. Shih worked for 2 years as an analyst in the Coverage and Analysis Group at the Centers for Medicare & Medicaid Services (CMS) where he worked on Medicare coverage policy for medical devices, pharmaceuticals, and procedures. Prior to joining CMS, he was a fellow in the Agency for Healthcare Research & Quality, where he worked on CER evidence reports and systematic reviews in the Effective Health Care Program.

Dr. Shih received both his PhD in health economics and his MHS in health policy from the Johns Hopkins Bloomberg School of Public Health.

References

• Quality measures and performance standards. 2013 ACO quality documents: narrative and technical specifications. Centers for Medicare & Medicaid Services website. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality_Measures_Standards.html. Accessed February 18, 2014.
• Chronic conditions chartbook: 2012 edition. Centers for Medicare & Medicaid Services website. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/2012ChartBook.html. Accessed February 15, 2014.
• Romley J, Goldman D, Eber M, et al. Cost-sharing and initiation of disease-modifying therapy for multiple sclerosis. Am J Manag Care. 2012;18(8):460-464.