genentech quality trend report · 31/03/2017 · the 2017 genentech quality trend report...
TRANSCRIPT
QUALITY TREND REPORTDriving the future of healthcare planning, policy, and innovation
2017
GENENTECH
SUMMARYIt first emerged in the mid-1800s to improve patient safety through sanitization and hygiene
standards. Now, quality permeates all aspects of healthcare through an expanding, dynamic
ecosystem of mechanisms and stakeholders.
Quality is now more important than ever before. Cost control was historically considered
indicative of value, but a growing emphasis on outcome optimization has led to an increase in
quality-driven policy, in turn driving a set of emerging trends, including patient and provider
centric systems, alternative payment models, and improved use of data and technology. As
the quality landscape diversifies, stakeholders face pressure to adopt an evidence-based
approach to provide the highest quality of care to patients. To meet these demands, traditional
stakeholders are expanding beyond their typical roles, new stakeholders are finding their
niche, and opportunities for collaboration and strategic partnerships are emerging.
The critical role that quality plays in the healthcare landscape will only continue to expand, as
will its relevance. Quality can no longer be considered a siloed practice; it is an imperative and
integral component of healthcare planning, policy, and innovation.
Quality has evolved into an integrated and expected component of the holistic healthcare landscape.
The 2017 Genentech Quality Trend Report summarizes existing, publicly available research to provide a foundational understanding of healthcare quality and its importance, to raise awareness of external impacts, and to identify key considerations shifting the quality landscape. The report content was guided by an internal advisory committee that comprises cross-functional experts and opinion leaders across Genentech.
METHODOLOGY
CONTENTSCOLOR KEY SUMMARY
QUALITY DEFINED - STRIVE FOR VALUEDefinitionsEvolution of Quality in the US
MECHANISMS FOR DRIVING QUALITY Quality Measures Accreditation & CertificationPay for ReportingPay for Performance (P4P)Patient ToolsAlternative Payment Models (APM)Pathways & Guidelines Value Frameworks Transparency
MEET THE STAKEHOLDERSPatients/Consumers Healthcare ProvidersPayersQuality OrganizationsLife SciencesDigital Health CompaniesPolicymakersStakeholder MapsA Vision of Advanced Quality in Action
NOW NEXTQuality-Focused Policy Value-Driven PaymentsStrategic PartnershipsData & TechnologyThe Empowered Patient & The Transformation Of Provider Engagement
WHAT TO WATCHPrevalance of QualityOn the HorizonReferences
2
456
10111112121313141414
15161718192021222325
262729333539
42424344
INTRODUCTION
QUALITY DRIVERS
QUALITY IN ACTION
QUALITY TRENDS
CONCLUSIONS
INTRODUCTION - 54 - INTRODUCTION
QUALITY TREND REPORT 2017
INTRODUCTIONQuality of care is a rapidly evolving driver of the complex healthcare ecosystem. This evolution has taken the national quality landscape from patient safety standards, to accreditation and transparency, and now, to the advancement of patient-centricity and beyond.
What can we expect from this evolving network of people, tools, and technology that pushes us to imagine a world where patients are the drivers of their care, and providers, policymakers, payers, life sciences companies, and other critical players, share a common focus on a healthier population?
This inaugural Quality Trend Report seeks to enhance the general understanding of quality and highlight key activities on the horizon. The report introduces the fundamental elements of quality, presents quality-related terminology, provides a chronological snapshot of the history of quality in the U.S., and offers an overview of quality mechanisms and select set of stakeholders. This report also highlights the dynamic web of policy, payment strategies, partnerships, data and technology, and the evolving roles of patients and providers that all play into quality’s growing prevalence.
As the future of the national healthcare system unfolds, we are assured that quality’s role will continue to transform and the trends discussed here, will evolve and expand.
Health and Medicine Division of the National Academies
–
is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Quality1
INTRODUCTION - 54 - INTRODUCTION
QUALITY TREND REPORT 2017
DEFINITIONSAccountable Care Organizations (ACO)2 - Group of doctors, hospitals and other health care providers who come together voluntarily to give coordinated high quality care to specific patients, most often Medicare patients.
Accreditation3 - Formal process by which a recognized body, usually a non-governmental institution, assesses and recognizes that a healthcare organization meets applicable, pre-determined standards.
Affordable Care Act (ACA)4 - Health reform legislation passed by Congress and signed into law in March 2010 that includes a long list of health-related provisions intended to extend coverage to millions of uninsured Americans, to implement measures that will lower health care costs and improve system efficiency, and to eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions.
Alternative Payment Models (APM)5 - Approach that gives added incentive payments to provide high-quality, cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
Clinical Practice Guidelines (Guidelines)6 - Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.
Electronic Health Records (EHR)7 - Computerized medical file that contains the history of a patient’s medical care and enables patients to transport their health care information with them at all times.
Healthcare Transparency8 - Access to accurate and comprehensive cost and quality information before medical treatment.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)9 - Legislation that allowed persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships and most notably created privacy standards for protected health information (PHI).
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)10 - Legislation that overhauls Medicare’s payments to clinicians by creating strong incentives for them to participate in APMs that require financial risk-sharing for a broad set of health services and that are designed to improve quality.
Pathways - Clinical pathways are standardized, prescriptive treatment protocols aimed at reducing treatment variation and managing medical spend through limited treatment options.
Patient-Centered Care11 - Care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.
Patient-Generated Health Data (PGHD)12 - Health-related data including health history, symptom, biometric data, treatment history, lifestyle choices, and other information, created, recorded, gathered or inferred by or from patients or their designees.
Pay for Performance (P4P)13 - Programs that reward providers for driving high performance in quality delivery and outcomes and incentivize value-based outcomes.
Pay for Reporting14 - Program that provides incentives for reporting, and penalties for not reporting, data on various quality measures.
Quality Measures15 - Tools that help measure or quantify healthcare processes, outcomes, patient perceptions, organizational structure and systems associated with the ability to provide high-quality healthcare.
Telehealth16 - Mode of delivering healthcare services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site.
Value17 - Outcomes of patient care relative to cost and time.
Value Frameworks18 - Structure that guides assessment of the value of medical services, including drugs, medical devices, and procedures.
Wearable Technology19 - Category of technology devices that can be worn by a consumer and often include tracking information related to health and fitness.
of Quality in the US
Quality has drastically transformed over the last two centuries. The 19th through mid-20th century was marked
by the contributions of individual innovators, who pioneered the early stages of the quality movement and
established accreditation and definitions for quality. By the mid-20th century, quality expanded beyond
independent experiments to earn its place on the national agenda. Over the last two decades, the quality
movement has advanced into an integral component of healthcare planning, policy, and innovation.
Several medical professionals, such as Florence Nightingale, document their e�orts to implement sanitization and hygiene standards to improve patient safety. These records demonstrate early quality improvement exploration.
EVOLUTION
INNOVATE
TRANSFORM
MID 1800'S - EARLY 1900'S
The Joint Commission creates the first accreditation process. Today, The Joint Commission continues as an instrumental driver in the quality ecosystem.
195221
The Federal Government establishes Medicare and Medicaid programs via the Social Security Amendments of 1965. This leads to the creation of what is now known as Centers for Medicare and Medicaid Services (CMS), a quality leader in U.S. healthcare policy, programs, and guidelines.
196522
Dr. Donabedian introduces the Quality Measurement Framework: structure, process, and outcomes. This framework sets the foundation for gauging healthcare quality and is still regarded as the basis for quality measurement.
196623
The Institute of Medicine (now referred to as The National Academy of Medicine) forms to focus on evaluating, informing, and improving quality of healthcare delivery. Most famously, IOM publishes "To Err is Human" (1998) and "Crossing the Quality Chasm" (2000).
1970
The American College of Surgeons develops the first set of hospital standards. This marks preliminary e�orts to structure quality e�orts.
EARLY 1900'S20
The Health Maintenance Organization (HMO) Act of 1973 passes, serving as the Federal Government's first systematic approach to managing the cost of care.
197324 The Federal Government establishes the Agency for Health Care Policy and Research via the U.S. Department of Health and Human Services. This new entity focuses on generating evidence and driving quality improvement.
198927
National Committee for Quality Assurance (NCQA) is founded as the first accrediting body for health plans and develops The Healthcare E�ectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers & Systems (CAHPS) creating new standards for health plans.
199028
IOM moves clinical guideline development forward witih their release of Clinical Practice Guidelines: Directions for a New Program, later updated in 2011.
199029
The Institute of Healthcare Improvement (IHI) is launched and becomes a global force, viewed as a leader in understanding and driving quality improvement. IHI eventually establishes the Triple Aim, which is regarded as the guiding principle of quality.
199130
The Federal Government passes the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This is the first federal legislation passed to regulate patient privacy and information access. This is a major step forward in patient empowerment and privacy.
199631
Early quality improvement organizations are established in response to poor outcomes. This movement demonstrates a national, collective response to negative outcomes resulting from PPS implementation.
198325
The Prospective Payment System (PPS) is implemented. These early days of payment reform compromise quality, which spurs new e�orts to improve outcomes and processes.
198224
The patient experience becomes a relevant component of quality measurement. For example, Press-Ganey is created to match science of survey design with hospital administration. These surveys help hospitals track their patients’ satisfaction and compare it with that of similar organizations.
198526
INTRODUCTION - 76 - INTRODUCTION
QUALITY TREND REPORT 2017
of Quality in the US
Quality has drastically transformed over the last two centuries. The 19th through mid-20th century was marked
by the contributions of individual innovators, who pioneered the early stages of the quality movement and
established accreditation and definitions for quality. By the mid-20th century, quality expanded beyond
independent experiments to earn its place on the national agenda. Over the last two decades, the quality
movement has advanced into an integral component of healthcare planning, policy, and innovation.
Several medical professionals, such as Florence Nightingale, document their e�orts to implement sanitization and hygiene standards to improve patient safety. These records demonstrate early quality improvement exploration.
EVOLUTION
INNOVATE
TRANSFORM
MID 1800'S - EARLY 1900'S
The Joint Commission creates the first accreditation process. Today, The Joint Commission continues as an instrumental driver in the quality ecosystem.
195221
The Federal Government establishes Medicare and Medicaid programs via the Social Security Amendments of 1965. This leads to the creation of what is now known as Centers for Medicare and Medicaid Services (CMS), a quality leader in U.S. healthcare policy, programs, and guidelines.
196522
Dr. Donabedian introduces the Quality Measurement Framework: structure, process, and outcomes. This framework sets the foundation for gauging healthcare quality and is still regarded as the basis for quality measurement.
196623
The Institute of Medicine (now referred to as The National Academy of Medicine) forms to focus on evaluating, informing, and improving quality of healthcare delivery. Most famously, IOM publishes "To Err is Human" (1998) and "Crossing the Quality Chasm" (2000).
1970
The American College of Surgeons develops the first set of hospital standards. This marks preliminary e�orts to structure quality e�orts.
EARLY 1900'S20
The Health Maintenance Organization (HMO) Act of 1973 passes, serving as the Federal Government's first systematic approach to managing the cost of care.
197324 The Federal Government establishes the Agency for Health Care Policy and Research via the U.S. Department of Health and Human Services. This new entity focuses on generating evidence and driving quality improvement.
198927
National Committee for Quality Assurance (NCQA) is founded as the first accrediting body for health plans and develops The Healthcare E�ectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers & Systems (CAHPS) creating new standards for health plans.
199028
IOM moves clinical guideline development forward witih their release of Clinical Practice Guidelines: Directions for a New Program, later updated in 2011.
199029
The Institute of Healthcare Improvement (IHI) is launched and becomes a global force, viewed as a leader in understanding and driving quality improvement. IHI eventually establishes the Triple Aim, which is regarded as the guiding principle of quality.
199130
The Federal Government passes the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This is the first federal legislation passed to regulate patient privacy and information access. This is a major step forward in patient empowerment and privacy.
199631
Early quality improvement organizations are established in response to poor outcomes. This movement demonstrates a national, collective response to negative outcomes resulting from PPS implementation.
198325
The Prospective Payment System (PPS) is implemented. These early days of payment reform compromise quality, which spurs new e�orts to improve outcomes and processes.
198224
The patient experience becomes a relevant component of quality measurement. For example, Press-Ganey is created to match science of survey design with hospital administration. These surveys help hospitals track their patients’ satisfaction and compare it with that of similar organizations.
198526
INTRODUCTION - 76 - INTRODUCTION
QUALITY TREND REPORT 2017
President Clinton’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry publishes the “Consumer Bill of Rights” and the following year, “Quality First: Better Health Care for All Americans.” The Clinton administration’s active voice advances the public dialogue around patient experience as an integral component of quality, and is widely regarded as a pivotal force for elevating the role of the patient in their care.
199732
The Leapfrog Group is founded by a group of business leaders, who pioneer the concept of leveraging transparency to improve quality. The group collects and reports hospital performance data for consumer access via the Leapfrog Group Hospital Survey. Hospitals are assigned letter grades through the Hospital Safety Grade initiative. This is the first widescale instance of consumer access to comparative hospital data.
200034
CMS and the Agency for Healthcare Research and Quality (AHRQ) create the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This survey is administered to adult hospital inpatients after discharge. This is the first federal patient experience measurement and reporting initiative.
200235
CMS launches the Healthcare Quality Alliance (HQA), a public-private collaboration that develops Hospital Compare website, the first federally-funded website of its kind. Hospital Compare grows from publicly reporting 10 core process measures in 2005, eventually adding consumer satisfaction data (HCAHPS) and mortality outcomes data.
200236
The country's first Pay For Reporting (P4R) and Pay For Performance (P4P) programs are introduced, and the Medicare Modernization Act (MMA) introduces the first hospital reporting measures. The Joint Commission's Surgical Care Improvement Project (SCIP) and CMS' Hospital Inpatient Quality Reporting (IQR) become the first national P4R programs. The Integrated Health-care Association (IHA) creates California's first P4P program, which is now the largest P4P program in the country.
200337
IHI develops Triple Aim, which stresses improved patient experience of care, improved population health, and reduced per capita price of care. The Triple Aim approach is globally regarded as a driving force for propelling quality.
200730
The National Quality Forum (NQF) is created. NQF develops a set of metrics for quantifying and reporting on national healthcare quality e�orts that becomes the “gold standard” followed by CMS and many other healthcare purchasers. The positive response from purchasers signals consensus on the metrics, which leads to national adoption. NQF also opens the door for multidisciplinary collaboration.
199933
The American Reinvestment and Recover Act (ARRA) and Health Information Technology for Economic and Clinical Use (HITECH) Act Passes. Incentives for the implementation and meaningful use of electronic health records go into e�ect. This marks the largest push for electronic health records to date, and serves as a foundation for improving data, technology, and quality.
200938
The 2010 A�ordable Care Act (ACA) passes, ushering in a new era for healthcare that puts quality and access to care at the center. This legislation mandates the development of the Health Insurance Marketplace, a single place where consumers can apply for and enroll in private health insurance plans. It also fosters innovative design of and testing for healthcare payment and delivery, allows for better alignment between Medicare and Medicaid, and establishes the National Quality Strategy.
201039
The ACA implements accountable care organizations (ACOs) and releases the National Quality Strategy, which pushes to improve and incentivize coordination of care between providers and payers. Additionally, PCORI begins operations.
201140
ACA implementation begins, marking the largest expansion of healthcare and social welfare to date. Coverage expands to many Americans who previously did not have coverage.
201440
The Medicare and CHIP Reauthorization Act (MACRA) of 2015 passes, rolling out a merit-based incentive payment system (MIPS) and encouraging participation in advanced payment models (APMs). This sweeping legislation consolidates three reporting programs into one streamlined set of requirements.
201541
VS
ADVANCE
MACRA
NEXT
INTRODUCTION - 98 - INTRODUCTION INTRODUCTION - 98 - INTRODUCTION
QUALITY TREND REPORT 2017
President Clinton’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry publishes the “Consumer Bill of Rights” and the following year, “Quality First: Better Health Care for All Americans.” The Clinton administration’s active voice advances the public dialogue around patient experience as an integral component of quality, and is widely regarded as a pivotal force for elevating the role of the patient in their care.
199732
The Leapfrog Group is founded by a group of business leaders, who pioneer the concept of leveraging transparency to improve quality. The group collects and reports hospital performance data for consumer access via the Leapfrog Group Hospital Survey. Hospitals are assigned letter grades through the Hospital Safety Grade initiative. This is the first widescale instance of consumer access to comparative hospital data.
200034
CMS and the Agency for Healthcare Research and Quality (AHRQ) create the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This survey is administered to adult hospital inpatients after discharge. This is the first federal patient experience measurement and reporting initiative.
200235
CMS launches the Healthcare Quality Alliance (HQA), a public-private collaboration that develops Hospital Compare website, the first federally-funded website of its kind. Hospital Compare grows from publicly reporting 10 core process measures in 2005, eventually adding consumer satisfaction data (HCAHPS) and mortality outcomes data.
200236
The country's first Pay For Reporting (P4R) and Pay For Performance (P4P) programs are introduced, and the Medicare Modernization Act (MMA) introduces the first hospital reporting measures. The Joint Commission's Surgical Care Improvement Project (SCIP) and CMS' Hospital Inpatient Quality Reporting (IQR) become the first national P4R programs. The Integrated Health-care Association (IHA) creates California's first P4P program, which is now the largest P4P program in the country.
200337
IHI develops Triple Aim, which stresses improved patient experience of care, improved population health, and reduced per capita price of care. The Triple Aim approach is globally regarded as a driving force for propelling quality.
200730
The National Quality Forum (NQF) is created. NQF develops a set of metrics for quantifying and reporting on national healthcare quality e�orts that becomes the “gold standard” followed by CMS and many other healthcare purchasers. The positive response from purchasers signals consensus on the metrics, which leads to national adoption. NQF also opens the door for multidisciplinary collaboration.
199933
The American Reinvestment and Recover Act (ARRA) and Health Information Technology for Economic and Clinical Use (HITECH) Act Passes. Incentives for the implementation and meaningful use of electronic health records go into e�ect. This marks the largest push for electronic health records to date, and serves as a foundation for improving data, technology, and quality.
200938
The 2010 A�ordable Care Act (ACA) passes, ushering in a new era for healthcare that puts quality and access to care at the center. This legislation mandates the development of the Health Insurance Marketplace, a single place where consumers can apply for and enroll in private health insurance plans. It also fosters innovative design of and testing for healthcare payment and delivery, allows for better alignment between Medicare and Medicaid, and establishes the National Quality Strategy.
201039
The ACA implements accountable care organizations (ACOs) and releases the National Quality Strategy, which pushes to improve and incentivize coordination of care between providers and payers. Additionally, PCORI begins operations.
201140
ACA implementation begins, marking the largest expansion of healthcare and social welfare to date. Coverage expands to many Americans who previously did not have coverage.
201440
The Medicare and CHIP Reauthorization Act (MACRA) of 2015 passes, rolling out a merit-based incentive payment system (MIPS) and encouraging participation in advanced payment models (APMs). This sweeping legislation consolidates three reporting programs into one streamlined set of requirements.
201541
VS
ADVANCE
MACRA
NEXT
INTRODUCTION - 98 - INTRODUCTION INTRODUCTION - 98 - INTRODUCTION
QUALITY DRIVERS - 1110 - QUALITY DRIVERS
QUALITY TREND REPORT 2017
QUALITY DRIVERS
MECHANISMS FOR DRIVING QUALITYAs the quality ecosystem becomes more complex, the list of mechanisms for defining, measuring, and delivering quality continues to grow. Many emerging mechanisms reflect a shift from a longstanding focus on cost control to one of quality outcome optimization.
QUALITY DRIVERS - 1110 - QUALITY DRIVERS
QUALITY TREND REPORT 2017
Asthma Medication Ratio (AMR)42
is an example of a measure that is endorsed by the National Quality Forum (NQF) and evaluates the percentage of patients 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
Quality measures15 are tools that help measure or
quantify healthcare processes, outcomes, patient
perceptions, organizational structure and systems
associated with the ability to provide high-quality
healthcare. Quality measures are related to one or more
quality goals for healthcare.
Quality measures were developed as a solution to drive
better approaches to care, and ultimately, to improve
outcomes for patients. Measures used by national quality
programs such as CMS’ Merit-Based Incentive Payment
System (MIPS under MACRA) undergo a rigorous process
of design, testing, submission for endorsement, and open
comment before they are incorporated into the program.
The process often takes years.
QUALITY MEASURES
Healthcare industry accreditation and certification programs first emerged
by way of The Joint Commission in the early 1950s to provide voluntary
hospital accreditation. Now, voluntary and mandatory accreditation
and certification programs across healthcare serve to ensure provider
compliance with industry standards.
In addition to The Joint Commission, The National Committee for Quality
Assurance (NCQA)43 has been instrumental in bringing validity to the value
of accreditation. NCQA collaborates with stakeholders across the healthcare
industry to build consensus on what is important to define quality and how
it should be measured. The accreditation process would have little impact
on healthcare quality if not for the general consensus that it should be
measured, and that the NCQA award scale is an accurate benchmark of it.
ACCREDITATION & CERTIFICATION
QUALITY DRIVERS - 1312 - QUALITY DRIVERS
QUALITY TREND REPORT 2017
Pay for reporting programs provide incentives for
reporting, and penalties for not reporting, data on
various quality measures. Incentives are tied to
the act of providing data, but not to performance.
Centers for Medicare and Medicaid Services
(CMS) has established multiple pay-for-reporting
programs for physicians, hospitals, and clinics for
which there are robust quality measure sets that
a provider must select from to provide data, or be
subject to a penalty.
PAY FOR REPORTING Hospital Inpatient Quality
Reporting Program (IQR)44
is a pay for reporting program established as part of the 2003 Medicare Modernization Act. The program covers more than 80 measures, which are reported on Hospital Compare, accessible to consumers. IQR is one of three key hospital inpatient programs with associated quality measures (the other two are Hospital Value-Based Purchasing Program and Hospital Acquired Conditions Reduction Program).
P4P programs reward providers for driving high
performance in quality delivery and outcomes;
P4P incentivize value-based outcomes, rather
than healthcare’s traditional focus on volume-
based care. These programs set incentives
beyond whether a provider reports performance;
a provider must meet a certain benchmark
within reported data to receive financial rewards.
Those who do not meet the benchmark receive a
performance-based payment adjustment.
PAY FOR PERFORMANCE (P4P) Integrated Healthcare
Association’s (IHA)45
Value-Based P4P program in California is an example of an effective P4P implementation. This program spans 10 health plans and over nine million Californians. It leverages an immense amount of reported data to drive quality improvement in collaboration with providers. It also serves as a national model as public and private payers increasingly entertain implementing value-based programs with performance incentives.
QUALITY DRIVERS - 1312 - QUALITY DRIVERS
QUALITY TREND REPORT 2017
Patient tools are a constantly-evolving set of devices,
community networks, and information channels used by
patients to navigate and understand the healthcare system,
their health, and overall wellbeing. These provide insights that
empower patients to make more informed decisions about
lifestyle choices, healthcare providers, health plans, and
therapeutic protocols.
Early patient tools were largely focused on provider
information portals and public reporting resources, which
allow patients to select a provider based on comparative data.
Patient tools now provide direct, personalized, real-time
information that help make decisions about one’s health and
healthcare. This is best reflected in the rising prevalence of
technology such as wearables, digital patient forums, and
pricing transparency tools. This shift has led to increased
patient awareness of quality performance and outcomes;
patients are now selecting health plans and providers they feel
best meet their needs and their expectations for care.
As a result, providers are showing greater commitment
towards providing high-quality patient experience and
outcome optimization.
PATIENT TOOLS
An APM46 is a payment approach that gives added
incentive payments to provide high-quality, cost-efficient
care. APMs can apply to a specific clinical condition, a care
episode, or a population. These are paths created to allow
providers and payers to share in financial risk of, and reap
the financial rewards from, better outcomes and efficient
delivery of high-quality care. While CMS has formalized
APMs through various programs, APMs also exist in private
payer contracts.
ALTERNATIVE PAYMENT MODELS (APM) The Next Generation
ACO Model47
builds upon the Pioneer ACO Model and the Medicare Shared Savings Program (MSSP), with 45 ACOs participating in an effort to achieve improved care coordination and overall quality. The program emphasizes collaboration between patients and providers in order to test the hypothesis that:
Strong Financial Incentives for ACOs + Tools to Improve Patient Engagement and Care Management = Improved Health Outcomes and Reduced Spending
14 - QUALITY DRIVERS
QUALITY TREND REPORT 2017
PATHWAYS & GUIDELINES
VALUE FRAMEWORKS
Providers and payers have historically capitalized on
information sharing to compare and improve performance,
and to allow for informed decisions when making referrals.
Now, transparency is an evolving and valuable tool that
empowers consumers to make informed choices with close
consideration to patient satisfaction, outcomes of care, and
cost of care.
Consumer access to quality and cost information is
rapidly becoming an expected component of the patient
experience. In fact, many low-rated health plans and
providers have suffered the effects of the growing emphasis
on patient awareness; poor performance in quality and cost
has led to lower consumer retention rates.
TRANSPARENCYOne of the earliestand most prominent examples of transparency in action is the CMS’ Hospital Compare49 web site, launched in 2005. This was the largest site displaying hospital quality scores, allowing any consumer to review a hospital’s performance prior to selecting care at that facility. Another well-known example is the Star Rating System50 used by Medicare to rate how well Medicare Advantage and prescription drug plans perform. Quality of care is just one of several categories rated.
Clinical practice pathways and guidelines assist healthcare
providers in clinical decision-making. Guidelines are an
evidence-based, comprehensive, and multidisciplinary sets
of clinical algorithms and supporting documents developed
to help providers decide when and how to use health service
intervention. Pathways are evidence-based treatment
protocols used by payers and clinicians. They are often
selections of the most cost-effective treatment options with
the greatest efficacy and that minimize toxicities.
Value Frameworks48 is an emerging field focused on measuring
the value of healthcare interventions. The growing number of
frameworks assess value differently, and are complicated by
varied stakeholder perspectives in the health care decision-
making process. However, they all work toward a common goal:
to better understand and quantify the benefits of a therapy or
class of therapies in relation to their costs or affordability.
Pathways and guidelines aim to improve quality of care for
all patients by mitigating inappropriate variation in care,
while maintaining a balance between cost-effectiveness
and efficacy. Guidelines are broader and present several
options, allowing providers to choose a treatment regimen
most suitable for an individual patient. Pathways are more
prescriptive and provide limited option.
Value frameworks are developed by professional medical
societies, cancer delivery centers and the Institute for Clinical
and Economic Review (ICER). It remains unclear how value
frameworks will guide decision making, as the full maturity of
value frameworks has yet to be realized.
To learn more visit: medicare.gov/hospitalcompare
QUALITY IN ACTION - 15
QUALITY TREND REPORT 2017
MEET THE STAKEHOLDERSThe list of invested stakeholders, and their roles within the quality ecosystem, is evolving along with the shift from cost savings to improved patient outcomes. To stay relevant, traditional stakeholders are expanding beyond their typical roles, while new stakeholders are finding their niche.
QUALITY IN ACTION
QUALITY TREND REPORT 2017
A patient / consumer is any person receiving, or registered to
receive healthcare services. Traditionally, the role of the patient
has been to comply with treatment protocols as directed by
providers. Now, patients are taking a proactive role, empowered
by information that allows them to make more informed decisions
about their treatment options. The healthcare system is shifting to
a focus on patient-centered care and outcomes and patients are
considered key stakeholders in the development of policies that
focus on quality and leverage improvements in quality for financial
incentives.
The patient voice is now at the forefront of healthcare quality,
through patient-reported outcomes, patient advisory groups,
patient advocacy groups, and other key patient-focused
organizations and efforts.
PATIENTS / CONSUMERS
All individuals in need of healthcare
services
Examples
• Navigating a convoluted network of
financial challenges for paying and
receiving care
• Paying rising premiums and deductibles;
increased out-of-pocket costs create
barriers to care
• Managing an increasingly complex and
self-directed care continuum
• Improving overall health literacy and
maximizing transparency tools
Key Challenges51
QUALITY IN ACTION - 17
Under federal regulations, a “healthcare provider”52 is someone
authorized to practice medicine or provide healthcare services
by the State and perform within the scope of their practice as
defined by State law. A healthcare provider is also any provider
from whom the University or the employee’s group health plan
will accept medical certification to substantiate a claim for
benefits. Providers:
Healthcare providers have been at the center of the healthcare
ecosystem for centuries. Until recently, a provider’s role was as
an independent decision maker for a patient. Today, providers
are one of many stakeholders who collaborate around patient
care. Technology, innovation and advanced care models are
becoming more important to this evolving role53.
• Care for critical or health sustaining needs through primary
care, specialty care and/or services, and mental healthcare,
in the form of in-person and/or virtual visits and treatment.
• Serve as thought leaders and champions for the healthcare
community, including academic research and development
and testing of treatment options.
HEALTHCARE PROVIDERS
Doctor of medicine or osteopathy, podiatrist, dentist,
chiropractor, clinical psychologist, optometrist, nurse
practitioner, nurse-midwife, clinical social worker
Examples
• Added administrative burden due to reporting and
other requirements
• Managing new technologies and disruptive innovation
that are transforming the healthcare ecosystem
• Increasing competition due to market consolidation
• Transitioning from traditional care model to a more
patient-centric collaborative model
• Transitioning to a value-based payment system where
providers are assuming greater financial risk, in part
due to new government regulations
• Ensuring the data used to assess quality is an
accurate representation of the care that was provided
• Growing emphasis on population health management
Key Challenges54
QUALITY TREND REPORT 2017
Payers are entities other than the patient that finance or reimburse
the cost of health services. Some examples include government
payers, insurance carriers, health plan sponsors such as employers
or unions, and other third-party payers. A payer provides health
coverage to its members. Specifically, payers:
Payers are critical components of the highly-privatized national
healthcare system; they can be the reason that providers receive
appropriate and timely compensation, and that members receive
timely care and have clear expectations on payment for services.
Public payers, namely Medicare and Medicaid, help ensure that
low-income individuals, seniors, and people with disabilities, receive
necessary healthcare coverage.
• Promote and pay for “medically necessary” care and services
• Mitigate risk of misuse or overuse of services
• Support timely access to high-quality care and services with
low-risk providers (i.e. those with high performance and proven
outcomes)
• Seek to facilitate positive member experiences
PAYERS
Private health plans, Government payers
(Medicare and Medicaid), Employer groups
Examples
• Containing costs amidst growing regulatory
pressures to provide coverage for a greater
volume of members including high-risk
populations, and the increasing cost of
medical innovation
• Reducing rates for public payers and reliance
on federal government to estimate the cost of
care for populations with growing needs
• Managing risk associated with federal
requirements and increased competition
due to an evolving payer landscape (i.e.
employers and unions)
• Predicting needs amidst significant market
uncertainty
Key Challenges
QUALITY IN ACTION - 19
• Surfacing quality issues for policy consideration
• Building consensus around what is important to quality,
how to measure it, and how to promote improvement
• Providing education and facilitating dialogue on
guidelines, policies, and trends
• Developing quality standards and measures to identify
opportunities for improvement
QUALITY ORGANIZATIONS
National Quality Forum (NQF), Agency for Healthcare
Research and Quality (AHRQ), Institute for Healthcare
Improvement (IHI), The Joint Commission (TJC),
National Committee for Quality Assurance (NCQA)
Examples
• Maintaining credibility and securing adequate
resources to keep up with rapid quality landscape
changes and advancements
• Building consensus among various stakeholders
• Balancing the needs to improve existing or
create new measures, while limiting the burden
of reporting and reducing the impact of less
meaningful measures
• Implementing timely quality measurements,
and navigating disease-specific measurement
challenges
Key Challenges
A quality organization is a government agency, nonprofit or
educational entity focused on elevating issues of healthcare
quality to the national healthcare agenda. Mission and resource
allocation are typically geared toward fostering initiatives and
policies integral to the future of healthcare quality. Quality
organizations develop quality measures, advocate for quality
issues, help pass legislation and champion national quality
goals. Additionally, quality organizations provide quality-related
certification and accreditation, education, and program tracks.
Primary functions include:
QUALITY TREND REPORT 2017
Life sciences encompasses biotechnology, medical device companies,
and the pharmaceutical industry. Life sciences companies seek to
research, discover, design, develop, and distribute innovative treatments
and products for diagnosing and treating diseases and medical
conditions55. Often, life sciences companies partner with academic
institutions and others to fund emerging research. A growing emphasis on
quality has led many organizations to focus on patient-centeredness and
outcomes throughout the development and commercialization processes.
Life sciences is an imperative industry to developing diagnostic and
treatment options, as well as emerging as key players in health policy.
Traditionally, companies provided feedback to legislators on key quality-
related policy, but some are now viewed as drivers and facilitators of quality
policy discussions, even organizing stakeholders for information sharing to
better understand how policy impacts the healthcare continuum56.
LIFE SCIENCES
Biotech, medical device, pharmaceutical, and
diagnostics companies
Examples
• Demonstrating product value while combatting
increasing public scrutiny around pricing57
• Managing copious amounts of regulations in
product development, medical oversight, and
commercialization processes
• Leveraging a limited window of time in which
a company can market a product without
competition58
• Connecting and leveraging quality in the early
stages of product development to improve
health outcomes58
Key Challenges
QUALITY IN ACTION - 21
DIGITAL HEALTH COMPANIES
Wearables and personal health tools,
transparency tools for price comparison,
data analytic collection and modeling
Examples
• Gaining credibility by developing tools
that are meaningful for both patients and
providers
• Meeting expectations to provide a unique
service or product in exchange for
compensation (e.g. reimbursement, value-
based payments, etc.)
• Developing and maintaining patient
engagement on platforms with limited
capabilities and access options
• Protecting personal health data
• Connecting with providers using relevant
information
Key Challenges59
Digital health is comprised of healthcare technologies that leverage a
variety of platforms including social media, user-generated content,
cloud-based services, and mobile platforms to improve the patient
experience. Digital health has recently emerged as an influential
healthcare stakeholder, challenging the way traditional healthcare
operates and delivers its care using technology to solve the multitude
of challenges facing healthcare today. Digital health specifically:
• Innovates for the way health is managed
• Seeks to empower patients and providers through ease, convenience,
and value
• Increases the movement toward data collection to inform better
decisions
• Increases patient awareness of quality and cost prior to making care
decisions
• Shifts consumer interactions with providers by improving proactive self
care and promoting new ways of care collaboration through connectivity
QUALITY TREND REPORT 2017
Policymakers work with all groups in the healthcare ecosystem
including constituents, pharma, quality organizations, patient
advocacy groups, providers, and digital health to understand
competing priorities and challenges, find alignment among these
groups, and present legislation that creates and funds necessary
programs.
Typically, policymakers respond to budget constraints, political
party priorities, constituency needs, and well-organized quality
and/or advocacy efforts when considering policy. This makes for
an extensive process, further challenged by election cycles and
changes in leadership.
POLICYMAKERS
Federal and State Government
Examples
• Advocating for proactive, strategic
healthcare planning amidst a reactive policy
environment
• Navigating approval processes and often-
deadlocked partisan politics
• Planning in an uncertain political landscape
Key Challenges
QUALITY IN ACTION - 23
QUALITY TREND REPORT 2017
to connect patients to information about
treatment and services. This expanded level
of information access added to the growing
movement to place patients in the center of the
healthcare landscape. Eventually, the ecosystem
shifted to a more “patient-considered” model
as patient experience emerged as a metric for
delivering successful care.
at the center of the ecosystem, where
they served as independent decision
makers in patient care. The patient’s role
was passive with a focus on compliance
with treatment protocols assigned by a
provider. Policymakers, payers, and life
science companies, played peripheral yet
important roles.
INNOVATE
TRANSFORM
The healthcare ecosystem was once focused on healthcare providers. Over time, this focus has transitioned to patients. Now, patient-centric care is advancing healthcare policy, planning and innovation.
Emerging healthcare technology provided new tools
The early healthcare ecosystem placed providers
24 - QUALITY IN ACTION
QUALITY TREND REPORT 2017
of the healthcare ecosystem, and introduces new stakeholders to support
new types and modalities of care. The care network consists of providers,
payers, life science companies, policymakers, digital health companies,
and quality organizations, all driving toward a patient-centered care model.
ADVANCE
The new direction of the healthcare ecosystem moves patients to the center
QUALITY IN ACTION - 25
QUALITY TREND REPORT 2017
A VISION OF ADVANCED QUALITY IN ACTION Rosalie is 31 years old and the single mother of a
six-year-old son, Alex and is a lawyer at a small law
firm. Her employer provides health insurance, but
in order to keep the monthly premiums affordable,
she has chosen a high-deductible health plan.
As such, her employer offers employees a health
benefits platform that provides information about
quality and costs of treatments.
Rosalie noticed that Alex had a cough and was not
sleeping well. One week later, she was informed
by Alex’s school that he was wheezing and
coughing after physical activities. Rosalie made
an appointment with Alex’s primary care provider
Dr. McKinley, a pediatrician. She conducted a
series of tests that showed Alex’s symptoms may
be indicative of asthma. She recommended that
Alex see a specialist. Rosalie remembered the
health benefits platform that helps make such care
decisions, and immediately called them.
The service helped Rosalie identify three options.
She then obtained and compared information
about the quality of the care each provided
including patient satisfaction and outcomes of
children with asthma, the cost that she would
incur if Alex were treated, and how quickly she
could get an appointment. She selected a provider
that specializes in pediatric asthma and allergies,
had good quality ratings, and offered affordable
care. She then contacted Dr. McKinley’s office
to inquire about her choice and obtain a referral.
Unfortunately, the provider’s typical wait time for a
new patient was weeks out. However, Dr. McKinley
informed Rosalie that she is in the same care
network as the specialist and would coordinate sharing
information and having Alex seen as soon as possible.
Dr. McKinley was able to secure an appointment just
two days later. After conducting a series of tests and
reviewing tests results and notes from Dr. McKinley,
the specialist wrote a prescription for a medication
that Rosalie had not heard of. The specialist provided
Rosalie with information about the treatment provided
by the manufacturer that informed her of side effects
and potential complications, and encouraged her to
also do her own research. Later that day, she turned
to social media where she connected with a support
group for parents of children with asthma. There, she
posted a question about any experiences parents had
with this medication. She received several responses,
some in favor of the treatment, others opposed. What
she found most valuable was the ability to connect with
other parents and ask them additional questions about
why they made their choices. Ultimately, she and the
specialist agreed to try Alex on the medication for two
months, with regular monitoring of his progress.
One month later, Rosalie and Alex returned to Dr.
McKinley. Rosalie was impressed that Dr. McKinley
had all of the notes and latest information about Alex’s
progress as the two providers had a single health
record for Alex. Rosalie shared with Dr. McKinley a new
mobile application that she was using to monitor Alex’s
asthma control and provide the data to his school and
healthcare providers.
26 - QUALITY TRENDS
QUALITY TREND REPORT 2017
QUALITY TRENDS
Healthcare is adjusting to an emerging emphasis on value-based care. This is reflected through a dynamic national policy conversation, the implementation of experimental payment models, a growing number of strategic partnerships, the evolving role of technology in care and the shift in provider-patient dynamics.
NOW NEXT
QUALITY TRENDS - 27
QUALITY TREND REPORT 2017
Over the last decade, value-driven, patient-centric policy has steadily gained momentum. This is evidenced by three major pieces of healthcare legislation that advance the goals of improving patient access, quality of care, and patient outcomes. However, there are often a variety of strategic approaches employed to improve quality, and thus, the policy landscape, along with federal resources and funding, continue to evolve.
Specifically, the Affordable Care Act (ACA), the Medicare Access and CHIP Reauthorization Act (MACRA), and the 21st Century Cures Act have heavily influenced the implementation of value-based healthcare.
QUALITY-FOCUSED POLICY TREN
D
The Affordable Care Act (ACA) was President Obama’s signature healthcare legislation that
expanded access to insurance for many Americans.
In addition to coverage expansions, the ACA advanced several quality initiatives:
• Creation of CMS’ Innovation Center - where many alternative payment models (APMs) are being
tested (e.g., ACOs, Oncology Care Model, Episodic Payment Models)
• Hospital Value-based Purchasing program - uses data reported under the Inpatient Quality
Reporting (IQR) program to increase payments to high performing hospitals
• Hospital Acquired Condition (HAC) program - reduces payment for the quartile of hospitals
performing the worst on the HAC quality measures composite score
• Value-based Payment Modifier - uses data reported under the Physician Quality Reporting System
(PQRS) and claims data to stratify the cost and quality of care provided and adjust payment
accordingly (Note: this program will sunset at the end of 2018 and will be replaced by MACRA
payment adjustments)
AFFORDABLE CARE ACT (ACA)88
28 - QUALITY TRENDS
QUALITY TREND REPORT 2017
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was bipartisan federal legislation
that replaces the former methodology for paying physicians.
The 21st Century Cures Act was bipartisan federal legislation that reforms how medical advances are
discovered, developed, and delivered.
MACRA aims to shift Medicare payments to a performance-based payment system with the creation
of the Quality Payment Program (QPP) which allows clinicians to choose between 2 tracks:
21st Century Cures created several data collection initiatives with the intent of improving patient
outcomes and driving patient-centered care, including:
1. MIPS - Combines the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier,
Meaningful Use, and Cost, in addition to a new performance category - Clinical Practice Improvement,
under a single program89.
2. Advanced Alternative Payment Models (APMs) - Give added incentive payments to provide high-
quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a
population. In addition to requiring EHR technology and quality measure reporting, clinicians must
take on significant shared financial risk of cost and savings89.
• Patient Experience Data Collection – The Federal Drug Administration (FDA) will create a plan to provide
guidance about the collection and use of patient experience data in drug development. The guidance
will have to address how the information is collected, submitted, and accuracy is confirmed. The FDA
will also submit reports to Congress assessing the use of experience data in 2021, 2026 and 2031.
• Real World Evidence Collection – The FDA will create a program to evaluate the use of “real world
evidence” in the drug approval process, which would be defined as data regarding the benefits or risks
of using a treatment from sources other than randomized clinical trials.
MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT (MACRA)44
21ST CENTURY CURES ACT89
QUALITY TRENDS - 29
QUALITY TREND REPORT 2017
BOTTOMLINE• While the future of the ACA is unknown, quality initiatives included in the ACA
have moved quality and value-based initiatives forward. • Progress made under the ACA is unlikely to be rolled back, and some
initiatives have already been accelerated under subsequent legislation.• While 2017 marks the first reporting year for MACRA, the CMS continues
to look for ways to control costs of the Medicare program while improving outcomes; however, changes with CMS’ Innovation Center could change the pace at which alternative payment models are adopted.
• As the need for better data and system interoperability grows, 21st Century Cures’ will bring a greater focus on patient experience and real world evidence, to the evolving healthcare landscape.
Value-based payment models aim to tie a provider’s payment
to outcomes and rate targets as opposed to the traditional fee-
for-service model, in which a provider’s payment is based on
volume of care delivered60. Whereas traditional fee-for-services
models incentivized providers based on volume of care provided,
value-based payment models reward improvements in pre-
defined metrics, including patient outcomes, patient satisfaction,
readmission rates, clinical processes, and cost per episode of
care61. The overarching goal of value-based payment models is to
promote better, more cost-effective care.
Value-driven payment models have emerged as a strategy to drive improvements in quality and reduce costs of healthcare delivery. They are growing in popularity among private and public payers due to the rising cost of care, emphasis on patient outcomes and in response to new legislative requirements.
VALUE-DRIVEN PAYMENTSTREN
D
30 - QUALITY TRENDS
QUALITY TREND REPORT 2017
FEE-FOR-SERVICES (FFS)62
The current, prevailing payment method in which doctors and other health care
providers are paid for each service performed. Traditional FFS model creates a platform
of “pay for volume” vs the value-based models emerging.
SHARED SAVINGS63
An alternative payment model (APM) that offers incentives for provider entities to reduce
healthcare spending for a defined patient population by offering a percentage of net
savings realized as a result of their efforts. This model has gained momentum with the
implementation of the Medicare Shared Savings Program and other similar APMs.
SHARED RISK64
An APM whereby providers cover a portion of costs if savings targets are not achieved.
Under this model providers take on more risk often with the opportunity for larger
financial gain. The passage of MACRA has given significant momentum to this model as
well as the “two-sided risk” models that incorporate shared savings and shared risk.
BUNDLED OR EPISODE OF CARE PAYMENTS65
A reimbursement model aimed at reducing costs whereby a single lump sum is paid to a
collective of providers, creating a platform of shared accountability. The Comprehensive
Care for Joint Replacement Model, implemented in 2016 is a recent example of this
APM implemented by CMS.
GLOBAL CAPITATION66
A reimbursement model whereby whole networks of hospitals and physicians receive
a single fixed monthly payment for enrolled health plan members - typically made on a
“per member per month” basis. This payment model requires a significant amount of
population management which can drive care improvements and overall quality.
PAYMENT MODELS
QUALITY TRENDS - 31
QUALITY TREND REPORT 2017
Traditional fee-for-service models are heavily entrenched in the healthcare ecosystem, so why are government and
private payers now moving toward value-based payment models? Three factors leading to value-based payment
models’ increasing prevalence are high cost of care, patient advocacy, and new legislative requirements.
The transition to value-based care is expected to continue as payers seek ways to address rising health care costs
and improve quality. However, value-based payment models are still evolving, and many providers are trying to meet
emerging requirements while operating within infrastructure designed for the fee-for-service payment model.
VALUE-BASED PAYMENT, WHY NOW?
WHAT TO EXPECT NEXT
The nation’s healthcare spending is the highest in the developed world. Fee-for-service payments
are considered a primary driver for these costs as they encourage the use of more services, and
more costly services, with fee-for-service spending estimated to reach $5 trillion by 2021. Moving
away from fee-for-service payments is believed to be critical in addressing incentives of volume-
based payments.
HIGH COST OF CARE67
While the U.S. spends more on healthcare than other developed nations, the country is ranked
poorly on several key health outcome measures, including life expectancy and prevalence of
chronic conditions. This suggests that cost of care (or volume of care delivered) is not necessarily
correlated with quality of care.
POOR OUTCOMES67
Over the last decade, healthcare legislation has increasingly incorporated value-based payment
models. Since the implementation of ACA, value-based payments make up nearly 20 percent
of healthcare payments. This number is expected to climb to 75 percent by 2020, in part due to
the recently-passed MACRA. MACRA incentivizes high-quality, efficient care and encourages
providers to move into risk-based alternative payment models, further shifting the system to value-
based payments.
NEW LEGISLATIVE REQUIREMENTS68
32 - QUALITY TRENDS
QUALITY TREND REPORT 2017
For example, the Medicare Shared Savings Program
mandates that providers measure performance on an
annual basis, tracking various measures67. The program
requires robust technology infrastructure for which
providers must financially invest and train staff to use
properly. This transition can be costly and time consuming.
While some payers are utilizing pay-for-performance, for
many providers MACRA will be their foray into a formal
value-based payment system; concerns about associated
costs of the logistics to implement the necessary systems to
properly meet the requirements are becoming all too real.
Still, the shift presents great opportunity to improve quality
of care. To meet requirements, providers are already
building partnerships for coordinated care to better serve
patients. This helps them to scale effective treatment to
relevant patient populations and improve required data
collection, sharing and analysis69.
Payers are beginning to use these data to help consumers
make more informed decisions around their care. Payers
rank providers using quality and cost metrics and make
these ratings available to consumers. These expanded data
points are intended to empower patient choice and drive
provider accountability69.
Over time, this expanded partnership between payers and
providers, and optimized data usage will lead to established
collaborative, coordinated care targeted to effectively
improve patient outcomes69.
BOTTOMLINE• While MACRA aims to accelerate value-driven care for government programs, private
payers are at different stages of transitioning to their own value-driven payment models.• As infrastructure, processes, outcomes, and patient reported outcomes, are
increasingly linked to compensation by payers, providers may need to rethink their approach to delivering high-quality care and proving that care is high-quality through IT systems’ data
• MACRA showcases value-driven care as an integral component of government payment programs. Private payers have already started to incorporate such payment models (most prominently pay-for-performance) into provider contracts.
• The shift to value-driven payment models presents financial and logistical challenges, but also provides opportunities for improved quality.
• As adoption of value-driven payment models increases, providers will need to improve consumer data collection and usage, ultimately targeted to deliver better and more integrated care.
QUALITY TRENDS - 33
QUALITY TREND REPORT 2017
The combination of rising expectations and requirements for quality of care and a growing number of healthcare providers is contributing to a more competitive healthcare industry. Providers are looking to meet new legislative requirements to provide higher quality care while maintaining revenue streams70. For large providers, this means heavy investment in IT infrastructure and staff training, both costly and time-intensive endeavors. For small providers, the necessary investment to meet these requirements is nearly impossible to make due to limited resources. Both large and
small providers are exploring strategic partnerships, aiming to mitigate costs through consolidation in one form or another.
For now, these partnerships present opportunity for innovative approaches to meet emerging expectations around quality of care71. However, some fear that too much focus on consolidation will eventually lead to less competition, higher prices, and thus lower accountability for quality of care.
VALUE-DRIVEN PAYMENTSSTRATEGIC PARTNERSHIPS TREN
D
ACA, MACRA, and other recent healthcare legislation have served as driving forces for strategic partnerships. For example,
ACA pay-for-performance program issues rewards and penalties to providers for delivering improved quality of care, based on
their reporting against determined metrics. Providers must invest in training and infrastructure upgrades in order to align with
program expectations and to ensure that they are equipped to collect and report the required metrics. Providers are faced
with a myriad of complicated, costly challenges72:
• IT investment to meet new EHR reporting requirements which are expensive and require expert support for proper setup
• Staff training to meet requirements for reporting
• Pressure to increase staff accountability throughout a patient’s care
• New requirements for managing and documenting patient follow up
• Weak or non-existent communication between different providers throughout a patient’s care
For large healthcare networks, overcoming these obstacles and meeting the growing list of quality-related requirements is
time-intensive and expensive. For small, resource-strapped providers, it is nearly impossible to accomplish without support.
In both cases, strategic partnerships73, including joint ventures and mergers, have become common solutions to stave off
industry competition and bridge the gaps to meet requirements.
STRATEGIC PARTNERSHIPS GAIN MOMENTUM
34 - QUALITY TRENDS
QUALITY TREND REPORT 2017
HIGHLIGHTED APPROACHES
An IDS is designed to help reduce redundancy in
care, and in turn, reduce cost of care and improve
patient outcomes. Independent providers facing
the increasingly competitive healthcare landscape
may consolidate with an IDS. An IDS owns one or
more hospitals, employs physicians across multiple
specialities, may provide nursing homes
or rehabilitation centers, and sometimes even
offers its own insurance plans (e.g. Kaiser
Permanente, Providence).
INTEGRATED DELIVERY SYSTEMS (IDS)74
ACOs allow providers to collaborate with other
providers, hospitals, and payers to improve quality of
care for patients. ACOs are attractive because they
help a provider distribute investment costs needed
to meet new requirements, while allowing for
financial reward if higher quality of care is delivered.
From 2012 to 2015, the number of ACOs increased
from 157 to 782, with 23 million American lives
covered. It is predicted that 105 million American
lives will be covered by ACOs in 2020. ACOs tend
to require larger scale operations, which makes it
challenging for smaller providers to participate.
ACCOUNTABLE CARE ORGANIZATIONS (ACO)75
Small and/or independent providers are facing
new reporting requirements outlined by MACRA
(e.g. EHR requirements), and the growing focus on
improved quality of care. Many of these providers
are looking to merge with other small providers, or
to be acquired by large networks to mitigate risk.
This alleviates short-term pressure, but mergers
and acquisitions bring a new set of problems:
bureaucracy, staff, and accountability all expend
valuable resources to manage.
MERGERS & ACQUISITIONS (M&A)
Consolidation is a practical approach to meeting
new requirements that elevate quality’s role in
healthcare. However, there are growing concerns
that consolidation will eventually drive up costs for
those purchasing healthcare services, which could
compromise the integrity of value-based care76.
For example, if an individual provider merges into
a larger network, the larger network’s share of the
health market increases. This allows the network
to charge insurance companies higher fees for
services. Ultimately, the burden of cost would fall
to consumers and the lack of competition removes
incentive to continually improve patient outcomes.
How can we foster competition in an age of
consolidation? Whatever the concept, it must be
approached with an acute sensitivity to why the
industry has arrived at this point in the first place:
providers are struggling to make investments
necessary to meet new requirements. The wrong
policy could worsen the existing resource strain.
ACOs have been touted as an example of
successful strategic partnerships across the
healthcare industry, something to be incentivized
over traditional M&A. ACO participation is
predicted to grow roughly four times its current
state by 202077. Regardless of these concerns,
the growing prevalence of consolidation shows no
sign of slowing. For now, these partnerships allow
providers to meet necessary requirements, and
bridge gaps in specialization, financial resources,
and interdisciplinary care.
WHAT TO EXPECT NEXT
QUALITY TRENDS - 35
QUALITY TREND REPORT 2017
BOTTOMLINE• Providers are now asked to deliver care to more patients, with higher quality but
with limited insight into a patient’s entire care. This is a driving force behind a significant spike in provider partnerships and consolidation.
• There are various approaches used to attempt to meet requirements and increase revenue. Integrated delivery systems, ACOs and M&A are three options.
• Some argue that this trend will eventually minimize competition, drive up healthcare costs, and ultimately jeopardize quality’s crucial role in healthcare.
• Strategic partnerships are only growing in popularity, in part out of necessity. ACO participation is increasingly at an exponential rate.
Technology is integral to supporting quality’s expanding relevance to healthcare. It serves as an effective vessel for patient data collection and analysis and connecting patients to tools that empower more informed decision making.
Technologies pose new opportunities, but also new challenges to healthcare stakeholders. Security breaches impact millions of consumers each year.
The multitude of electronic health record (EHR) systems are not yet interoperable, making information exchange more cumbersome or impossible. The potential for wearable technology and patient generated health data (PGHD) have not yet been harnessed. Despite these obstacles, these technologies, among many others, are driving improved quality of care.
DATA & TECHNOLOGYTREN
D
36 - QUALITY TRENDS
QUALITY TREND REPORT 2017
Improved data accessibility, integration, and analysis is transforming how healthcare is delivered and
how quality of care is monitored and measured. For example, large provider networks use EHRs to access
patient data in real time. Consumers use wearable technology to self-monitor biometrics. These technologies
have been developed to improve patient experience and outcomes.
While early EHRs were primarily used for medical
documentation and billing, recent iterations of
EHRs bring a vision of secure, real-time access
to a patient’s holistic health record, a vehicle for
precision medicine. There are hundreds of different
EHR systems available. In 2009, only 12 percent
of acute-care hospitals had implemented EHR
systems. By 2016, EHR adoption reached 99
percent, realizing a vision of robust EHR adoption78.
However, these systems are still not what they
were developed to be. Resource allocation for
implementing, maintaining, and ensuring quality
control is a common challenge. In addition, woefully
inadequate IT systems present high security risks,
and a lack of interoperability between the hundreds
of existing EHR systems weakens their potential
positive impact to patient outcomes79.
The transition from physical servers to cloud-based
systems has been slow due to security concerns.
The threat of security breaches is constant. In
2016, there were nearly 100 privacy attacks
on patient data, up 64 percent from 201578.
Understandably, many consumers fear that their
health information is vulnerable to hacking, and as
a result, may withhold critical health information
from providers which can lead to incomplete
medical histories. This directly impacts patient
outcomes, but can also affect health data analytics
and value-based reimbursements. Healthcare
providers have been reluctant to store patient data
in the cloud where it can be accessed from outside
of the provider network and integrated with other
healthcare systems; the transition to cloud-based
storage is a slow one80.
There is growing legislative pressure for
interoperability between various EHR systems
and other healthcare technology systems.
MACRA enshrined EHRs’ place in the
healthcare continuum as a component of payer
reimbursement contracts. 2016 21st Century
Cures Act includes several measures that
encourage EHR interoperability and patient access
to data, while disincentivizing information
blocking and making these systems easier
for physicians to use. In fact, failure to
comply with these measures could cost a
vendor its EHR certification81.
TECHNOLOGY IN ACTION: DATA’S GROWING ROLE IN QUALITY
EXAMPLE: EHRS
QUALITY TRENDS - 37
QUALITY TREND REPORT 2017
Wearable technology has the
potential to unlock value from patient
generated health data (PGHD), which
refers to data generated by a patient
via wearables or consumer health
applications (frequently accessed by
mobile devices). This is particularly
exciting when considering the growing
prevalence of value-based care, where
payers incorporate long-term patient
outcomes into reimbursement models.
PGHD provides ample opportunity to
improve patient outcomes. It engages
patients in their own care and, when
used by providers, PGHD can provide
a more holistic picture of a patient’s
health to make better-informed
care decisions. However there are
challenges facing the widespread
integration of PGHD into patient care:
EXAMPLE: WEARABLE TECHNOLOGY
A wearable device or consumer health application collects
a robust amount of data. While a patient may see this data
as important to their care, many healthcare systems lack
the technical infrastructure and data science training
to draw meaningful insights. This makes it difficult to
demonstrate the true value of PGHD to a patient’s care and
often leads to providers neglecting PGHD as a potentially
important tool.
USING PGHD TO INFORM CLINICAL CARE12
If a provider does capture PGHD, it has to be a device
that meets one of the U.S. Food and Drug Administration
(FDA) sets of standards for data reliability. If not, a provider
must find a way to validate the data, or they may face
liability if they decide to use the unverified data to make a
care decision.
MEETING FDA STANDARDS
There is concern that integrating PGHD pulled from devices
with patient EHRs may pose security risks to EHR systems,
though EHR vendors are responsible for protecting this
data under HIPAA82. However, the chain of custody for data
collected is still unclear. Who owns PGHD at which point,
and who is responsible for its security? The answer to this
question could shift the burden of security to the consumer
or device manufacturer, rather than the provider and/or
EHR vendor beholden to HIPAA standards.
MITIGATING SECURITY RISKS
38 - QUALITY TRENDS
QUALITY TREND REPORT 2017
As technology’s role in delivering quality care expands, so does the potential to improve care, and
challenges to reaching this potential. This forward momentum shows no signs of slowing, and there are
still many aspects of the patient experience that are not properly addressed by technology solutions.
WHAT TO EXPECT NEXT
Technology to streamline patient experience still lags behind other industries (e.g. banking and retail). Where the
banking and retail industries have transitioned to rely heavily on digital experiences to support customer needs,
most technology improvement has been around meeting requirements (e.g. upgrading technology infrastructure
to meet EHR system compliance), rather than strategic initiatives to improve patient experience. This is one of
the greatest opportunities for improved patient experience. This could take form in a mobile application that
allows a patient to check-in and submit records, before arriving at a hospital emergency room. This mobile
application could connect with a kiosk at the emergency room entrance, where the patient can check in, digitally
submit any necessary paperwork, and be placed into a queue based on urgency level. This could ultimately
lessen an emergency room wait time and improve the patient experience.
PLAYING CATCH-UP WITH OTHER SERVICE INDUSTRIES
Right now, patient data is collected and stored in many forms, from EHRs to wearable devices, but the struggle
to analyze and display information in a way that is meaningful to patients and providers remains inadequate.
Despite a growing number of incentives, providers struggle to properly understand and use the data collected,
because they have limited training in doing so. One proposed solution argues that data science training should
be incorporated into the core medical training curriculum83. While this is likely far off, the notion that data science
is entertained as a core function of a provider’s scope of work speaks volumes to the importance of technology,
and proper data analysis, to the future of quality of care.
TRAINING PROVIDERS FOR TOMORROW’S HEALTHCARE LANDSCAPE
The push for interoperability has led to health device manufacturers collaboration to define how devices
communicate with one another. Consumers are demanding access to data, and are often overwhelmed
by the myriad of devices available. The Open Connectivity Foundation (OCF)84 comprises over 300 device
manufacturers with the task of creating an open source project to allow all devices to communicate with one
another, despite manufacturer or operating system. This, and efforts like it, are indicative of a movement across
the industry: meeting consumer demands for information access and allowing interoperability to support a
better consumer experience.
ACHIEVING A TRULY INTEGRATED INTERNET OF THINGS
QUALITY TRENDS - 39
QUALITY TREND REPORT 2017
BOTTOMLINE• Technology’s role in quality of care is expanding rapidly. It is an integral component to storing,
managing, and using health data. • Security breaches that risk sensitive personal health data are a concern for health
organizations (for both patient experience and legal ramifications).• Barriers to interoperability are some of the most immediate challenges facing data’s growing
role in quality. Better communication protocols between devices are needed, within clinical information systems and across all devices and equipment.
• Even with growing investments, healthcare still lags behind other service industries in utilizing technology to improve customer experience. This is a large opportunity for improvement.
• The growing prevalence of PGHD empowers consumers to better understand their personal health. However, the pressure on providers to review, understand, and incorporate this data into patient care is a major challenge to unlocking this data’s potential value.
Patients are taking a more prominent role in their own care. They are demanding increased transparency and accountability from providers, and are becoming increasingly comfortable utilizing technological devices, pricing transparency tools, and online communities to inform decisions about treatment. This increased information access has led to a shift in how patients engage with their providers85. Until recently, a patient’s role has largely been to adhere to treatment protocols as directed by providers. Now, the patient serves as collaborator-in-care, contributing patient gathered health data (PGHD), online research, and opinion into treatment decisions. This new role empowers patients to drive their personal quality of care.
THE EMPOWERED PATIENT & THE TRANSFORMATION OF PROVIDER ENGAGEMENT
TREN
D
40 - QUALITY TRENDS
QUALITY TREND REPORT 2017
Patient empowerment is following the
broader cultural phenomenon of the
information age, where “expertise”
can be found at one’s fingertips in
less than a second. On a daily basis,
consumers research, compare, and
draw conclusions based on the broad
landscape of digital information available
to them. Consumers may begin to expect
the same level of information access with
their healthcare, a traditionally costly
industry that greatly impacts
every individual.
The increasing interest in information
access is creating space for
retail (e.g. wearable technology),
telecommunications (telehealth
companies), technology and wellness
and fitness industries to enter the
healthcare space. These non-traditional
stakeholders seek to fill consumer
demand for effective tools to proactively
monitor personal health and make
informed healthcare decisions. Three
examples of this emerging market are:
THE PATIENT’S EVOLVING ROLE Telehealth leverages telecommunications technologies to deliver
care to consumers remotely, and those seeking medical support
outside of clinic hours. This allows consumers to access professional
medical support outside of the traditional clinical environment, in a
way that is comfortable and convenient for the consumer. Telehealth
companies can support communities with limited access to expert
care. Telehealth is in its infancy and regulators are still working through
the role of policy in this emerging practice. However, over 60 percent
of adults with health insurance say they are open to virtual care
treatments, an indicator that consumers are becoming increasingly
comfortable with this new channel of care delivery, though some
research suggests in-person visits may have better diagnostic and
treatment outcomes86.
TELEHEALTH
Patient generated health data is a driving force behind the patient’s
emerging role as collaborator in care. Most wearables collect basic
activity information and providing real-time feedback to the wearer.
This feedback helps the consumer make lifestyle choices that may
improve their overall wellbeing. Nearly 80 percent of consumers
who use a wearable device want their providers to access the data
generated by the device86.
WEARABLE TECHNOLOGY
Online tools to help consumers compare provider costs and quality of
care delivered are growing in popularity. Patients can submit reviews
for providers and peruse other consumer reviews, pricing information,
quality scores, and other variables. While this information can be
helpful to a consumer’s decision making process, the tools are limited
in their ability to qualify quality of care, as most rely on consumer-
submitted data. Still, these tools allow for patient information access
and support empowered decision making.
PRICING TRANSPARENCY TOOLS
QUALITY TRENDS - 41
QUALITY TREND REPORT 2017
Empowered patients are significantly affecting the way care is delivered.
Healthcare is evolving into a more patient-centered experience, in large
part due to patient demand for information access, and the emerging
emphasis on self-directed care. Nontraditional stakeholders are stepping
up to meet these patient expectations, while healthcare providers are
racing to catch up.
As an example, a growing number of digital health companies offer
wearable technology to help patients monitor their health. In fact, at
least 60 percent of American adults actively track their diet, weight, or
exercise routine, while over 30 percent track symptoms, including blood
pressure, headaches or sleeping patterns12. Patients expect this data to
be incorporated into their care. However, providers are not yet equipped
with the data science skills to understand the significance of this data.
And there are substantial security concerns around integrating data from
wearable technology into EHRs. So, providers do not have the ability to
track this in real-time.
The shift toward patient-centric care will continue to transform
healthcare; consumers are becoming better equipped with information,
more empowered, and expect more from their healthcare provider than
ever before.
Traditionally, a provider serves as an
independent decision maker for a patient.
This is changing. As patients are taking
a more prominent role in their own care,
providers are tasked with adjusting to the
empowered patient’s call for transparency,
accountability, and a collaborative role
in their own care85. At the same time,
providers are expected to incorporate PGHD
into patient care while meeting growing
requirements for value-based care models,
both the product of patient-centered care’s
growing prevalence.
In theory, the integration of PGHD and
value-based care models will perpetuate
higher quality care87. However, these things
take time, extensive training, and financial
investment. The end result: a provider
population in the midst of transformation.
THE TRANSFORMATION OF PROVIDER ENGAGEMENT
WHAT TO EXPECT NEXT
BOTTOMLINE• The empowered patient is transforming expectations for how care is delivered. • Patients are demanding increased transparency, provider accountability, and a
collaborative role in their care. • The increasing expectation for information access is creating space for retail,
telecommunications, technology and wellness and fitness industries.• The provider’s role in healthcare is shifting to a more collaborative decision partner,
and they are expected to leverage PGHD into patient care. At the same time, they are adjusting to new requirements for value-based care models.
• Patients and providers are adjusting to a transforming engagement model. This transformation shows no sign of slowing; patient-centered care will continue to drive the future of healthcare.
CONCLUSION - 4342 - CONCLUSION
QUALITY TREND REPORT 2017
WHAT TO WATCHSince it first emerged in the mid-1800s, quality has become a crucial component to healthcare planning, policy and innovation. This is evidenced through its growing prevalence in all aspects of healthcare:
• Value-driven, patient-centric policy has gained substantial momentum over the last decade.
• Payers are transitioning from fee-for-service to value-based payment models.
• Providers are developing strategic partnerships to meet new value-based care requirements.
• Technology’s role in quality of care is expanding rapidly as digital health pioneers are working to improve outcomes through innovative technology.
• The empowered patient is transforming expectations for how care is delivered.
• Patients and providers are adjusting to a transforming engagement model; patient-centered care will continue to drive the future of healthcare.
THE PREVALENCE OF QUALITY
CONCLUSION - 4342 - CONCLUSION
QUALITY TREND REPORT 2017
While quality’s role expands, many elements of value-based and patient-centric care are still evolving. The impact of emerging quality trends on patient outcomes (e.g. value-based payment requirements, the growing role of patient gathered health data and tools to measure patient outcomes, and an increased number of provider partnerships) are still largely unknown. However, the common theme among all of these trends is to drive value-based, higher quality care. Infact, improved quality as the impetus for healthcare policy, planning and innovation is seemingly unwavering. As the policy debate continues, so does the empowered patient’s transformation of how care is delivered. Consumer push for increased quality is driving increased data and technology use and new industry players (e.g. telecommunications, retail) to bridge gaps in care. As traditional stakeholders (e.g. providers, policymakers, and payers) are faced with expanding patient needs, the healthcare ecosystem will continue to welcome those who can improve patient access to care.
ON THE HORIZON
CONCLUSION - 4544 - CONCLUSION
QUALITY TREND REPORT 2017
REFERENCES
20 - The 1919 “Minimum Standard” document. (n.d.). Retrieved November 6, 2016, from facs.org/about%20acs/archives/pasthighlights/minimumhighlight21 - The Joint Commission: over a century of quality and safety [PDF]. (2015). The Joint Commission.22 - Overview. (n.d.). Retrieved January 26, 2017, from cms.gov/About-CMS/Agency-Information/History/index.html?redirect=%2Fhistory%2F23 - Chun, J., MD, & Chao Bafford, A., MD, FACS. (2014). History and Background of Quality Measurement. Clinics in Colon and Rectal Surgery, 27(1), 5-9. doi:10.1055/s-0034-136691224 - Appendix B. A Brief History of Managed Care. (2013, May 13). Retrieved from ncd.gov/publications/2013/20130315/20130513_AppendixB25 - Marjoua, Y., & Bozic, K. J. (2012). Brief history of quality movement in US healthcare. Current Reviews in Muskuloskeletal Medicine, 5(4), 265-273. doi:10.1007/s12178-012-9137-826 - Siegrist, R. B., Jr., MBA, MS, CPA. (2013). Patient Satisfaction: History, Myths, and Misperceptions [Abstract]. AMA Journal of Ethics, 15(11), 982-987. Retrieved from journalofethics.ama-assn.org/2013/11/mhst1-1311.html27 - Agency for Healthcare Research and Quality. (2009, July 9). Retrieved November 6, 2016, from info.ahrq.gov/app/answers/detail/a_id/426/~/where-can-i-find-out-about-ahrqs-history%3F28 - Sennett, C. (1998). An introduction to the National Committee for Quality Assurance. Pediatric Annals, 27(4), 210-214. Retrieved from ncbi.nlm.nih.gov/pubmed/958950029 - Field, M., & Lohr, K. (1990). Clinical Practice Guidelines: Directions for a New Program - PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 31 January 2017, from ncbi.nlm.nih.gov/pubmed/2514403230 - Institute for Healthcare Improvement. (n.d.). Retrieved from ihi.org/about/pages/history.aspx31 - HIPAA History. (n.d.). Retrieved from hipaajournal.com/hipaa-history/32 - IHI Timeline [PDF]. (2013). Cambridge, MA: Institute for Healthcare Improvement.33 - NQF’s Mission and Vision. (n.d.). Retrieved from qualityforum.org/About_NQF/Mission_and_Vision.aspx34 - About The Leapfrog Group. (n.d.). Retrieved from leapfroggroup.org/about35 - Siegrist, R. B., Jr., MBA, MS, CPA. (2013). Patient Satisfaction: History, Myths, and Misperceptions [Abstract]. AMA Journal of Ethics, 15(11), 982-987. Retrieved from journalofethics.ama-assn.org/2013/11/mhst1-1311.html36 - Hospital Compare. (n.d.). Retrieved November 5, 2016, from cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/hospitalcompare.html37 - Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322–30. doi: 10.1086/505220.38 - HITECH Act Enforcement Interim Final Rule. (n.d.). Retrieved from hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/index.html?language=es39 - The Affordable Care Act: A Brief Summary [PDF]. (2011). Washington, DC: National Conference of State Legislatures.40 - Accountable Care Organizations (ACO). (n.d.). Retrieved November 4, 2016, from cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/Aco41 - MACRA. (n.d.). Retrieved November 4, 2016, from cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
2 - Glossary, Commonly Used Health Terms - Minnesota Dept. of Health. (2013). Health.state.mn.us. Retrieved 31 January 2017, from health.state.mn.us/clearinghouse/glossary.htm3 - Glossary of Terms. (2017). University of Rochester Medical Center. Retrieved 31 January 2017, from urmc.rochester.edu/quality/glossary.aspx#A4 - Affordable Care Act (ACA) definition. (2017). Health Insurance Resource Center. Retrieved 31 January 2017, from healthinsurance.org/glossary/affordable-care-act5 - Health Care Payment Learning and Action Network | Center for Medicare & Medicaid Innovation. (2017). Innovation.cms.gov. Retrieved 31 January 2017, from innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network6 - Clinical Practice Guidelines We Can Trust : Health and Medicine Division. (2011). Nationalacademies.org. Retrieved 31 January 2017, from nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx7 - Quality/Equality Glossary. (2013). RWJF. Retrieved 31 January 2017, from rwjf.org/en/library/research/2013/04/quality-equality-glossary.html8 - What is Healthcare Transparency?. (2017). Castlight Health. Retrieved 31 January 2017, from castlighthealth.com/solutions/healthcare-transparency9 - Health Insurance Portability and Accountability Act of 1996 (HIPAA) definition. (2017). Health Insurance Resource Center. Retrieved 31 January 2017, from healthinsurance.org/glossary/health-insurance-portability-and-accountability-act-of-1996-hipaa10 - MACRA: Disrupting the health care system at every level. (2016). deloitte.com. Retrieved 31 January 2017, from deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-dchs-macra.pdf11 - CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY. (2011). nationalacademies.org. Retrieved 31 January 2017, from nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf12 - Patient-Generated Health Data and its Impact on Health Information Management. (2015). Healthport.com. Retrieved 31 January 2017, from healthport.com/docs/default-source/whitepapers/wp_patientgeneratedhealthdata_120415_web.pdf?sfvrsn=2 13 - Yegian, J., Erickson, L., & Yanagihara, D. (2016). Charting a Course to Value in Physician Group Payment: Key Pay-for-Performance Design Decisions. iha.org. Retrieved 31 January 2017, from iha.org/sites/default/files/resources/value-based-p4p-design-issue-brief.pdf14 - Physician Quality Reporting System - Centers for Medicare & Medicaid Services. Cms.gov. Retrieved 31 January 2017, from cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRI15 - Quality Measures. (2016). Cms.gov. Retrieved 31 January 2017, from cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html16 - CA State Law Telemedicine/Telehealth Definition. cchpca.org. Retrieved 31 January 2017, from cchpca.org/ca-state-law-telemedicinetelehealth-definition17 - Porter, M. (2010). What Is Value in Health Care? — NEJM. New England Journal of Medicine. Retrieved 31 January 2017, from nejm.org/doi/full/10.1056/NEJMp1011024#t=article18 - ICER Value Assessment Framework – ICER. (2017). Icer-review.org. Retrieved 31 January 2017, from icer-review.org/methodology/icers-methods/icer-value-assessment-framework
1 - Crossing the Quality Chasm: The IOM Health Care Quality Initiative : Healthand Medicine Division. (2013). Nationalacademies.org. Retrieved 30 March 2017,from nationalacademies.org/hmd/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx
19 - Beal, V. What is Wearable Technology (wearable gadgets)? Webopedia Definition. Webopedia.com. Retrieved 31 January 2017, from webopedia.com/TERM/W/wearable_technology.html
Introduction Evolution of Quality in the US
Definitions
CONCLUSION - 4544 - CONCLUSION
QUALITY TREND REPORT 2017
42 - Asthma medication ratio: percentage of members 5 to 85 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. | National Quality Measures Clearinghouse. (2015). Qualitymeasures.ahrq.gov. Retrieved 31 January 2017, from qualitymeasures.ahrq.gov/summaries/summary/4970843 - About NCQA. (n.d.). Retrieved November 20, 2016, from ncqa.org/about-ncqa44 - Physician Quality Reporting System. (n.d.). Retrieved from cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRI45 - Yegian, J. M., Ph.D, Senior Vice President, Programs and Policy, Erickson, L., M.S.P.H., Director, Value Based P4P, & Yanagihara, D., M.P.H., Vice President, Performance Measurement. (2016). Charting a Course to Value in Physician Group Payment: Key Pay-for-Performance Design Decisions. Integrated Health Association, 22. Retrieved from iha.org/sites/default/files/resources/value-based-p4p-design-issue-brief.pdf46 - Health Care Payment Learning and Action Network. (n.d.). Retrieved from innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network47 - Next Generation ACO Model. (2017). Innovation.cms.gov. Retrieved 31 March 2017, from innovation.cms.gov/initiatives/Next-Generation-ACO-Model48 - Principles for Value Assessment Frameworks. (2016, March 30). Retrieved November 21, 2016, from phrma.org/codes-and-guidelines/principles-for-value-assessment-frameworks49 - Hospital Compare. (n.d.). Retrieved November 5, 2016, from cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/hospitalcompare.html50 - 2017 Star Ratings . (n.d.). Retrieved November 20, 2016, from cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-12.html
60 - CMS Value-Based Programs. (n.d.). Retrieved January 5, 2016, from cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html61 - CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) [PDF]. (2016, May 2). Washington, DC: Center for Clinical Standards and Quality Centers for Medicare & Medicaid Services (CMS).62 - Fee for Service. (n.d.). Retrieved January 20, 2017, from healthcare.gov/glossary/fee-for-service63 - Bailit, M., & Hughes, C. (n.d.). Key Design Elements of SharedSavings Payment Arrangements (Issue brief). The Commonwealth Fund.64 - Models of Value-Based Reimbursement (White Paper). (n.d.). Valence Health.65 - Seegobin, V. (2015, November 19). 3 types of risk-sharing models that create accountability. Retrieved from advisory.com/international/research/global-forum-for-health-care-innovators/the-forum/2015/11/risk-sharing-models-and-accountability66 - Capitation Models. (n.d.). Retrieved from hci3.org/thought-leadership/why-incentives-matter/capitation/capitation-models67 - Gerhardt, W., Korenda, L., Morris, M., MD, & Vadnerkar, G. (2015, March 20). The road to value-based care. Retrieved January 6, 2017, from dupress.deloitte.com/dup-us-en/industry/life-sciences/value-based-care-market-shift.html68 - Kraus, S., Hedin, A., & Walsh, A. (2016, January 9). Fee-For-Value Drives Trillion-Dollar Healthcare Opportunity. Retrieved from techcrunch.com/2016/01/09/fee-for-value-drives-trillion-dollar-healthcare-opportunity69 - Gallegos, A. (2016, October 3). Pediatricians partner with hospitals for value-based models. Retrieved from mdedge.com/pediatricnews/article/114832/practice-management/pediatricians-partner-hospitals-value-based-models70 - Ginsburg, P., PhD. (2016, March 16). Health Care Market Consolidations: Impacts on Costs, Quality and Access [PDF]. The Brookings Institution: Leonard D. Schaeffer Chair in Health Policy Studies, Senior Fellow and Director Center for Health Policy. Statement of Paul B. Ginsburg, Ph.D. before the California Legislature, Senate Committee on Health Informational Hearing71 - MACRA: Disrupting the health care system at every level (Issue brief). (2016). Deloitte Center for Health Solutions and the Deloitte Center for Regulatory Strategies.72 - Carmencio, A. (2016, July 12). Provider Consolidation and Its Effect on Spending and Prices. Retrieved from ahip.org/provider-consolidation-and-its-effect-on-spending-and-prices73 - Strategic Partnerships: Survival in Healthcare (Rep.). (2016, April). Retrieved from healthleadersmedia.com/report/intelligence/strategic-partnerships-survival-healthcare74 - Frakt, A. (2016, June 13). The Downside of Merging Doctors and Hospitals. New York Times. Retrieved from nytimes.com/2016/06/14/upshot/the-downside-of-merging-doctors-and-hospitals.html?_r=175 - Projected Growth of Accountable Care Organizations. (2015, December 23). Retrieved from leavittpartners.com/2015/12/projected-growth-of-accountable-care-organizations-276 - Dafny, L. S., & Lee, T. H. (2016, December). Health Care Needs Real Competition. Harvard Business Review. Retrieved January 14, 2017, from hbr.org/2016/12/health-care-needs-real-competition77 - Projected Growth of Accountable Care Organizations. (2015, December 23). Retrieved from leavittpartners.com/2015/12/projected-growth-of-accountable-care-organizations-278 - Conn, J. (2016, December 17). The 2016 Year In Review: Information Technology. Retrieved January 20, 2017, from modernhealthcare.com/article/20161217/MAGAZINE/312179841/the-2016-year-in-review-information-technology79 - Report to Congress: Challenges and Barriers to Interoperability [PDF]. (2015, December). The Health Information Technology Policy Committee.80 - Is Storing Health-care Data in the Cloud a Good Idea? (2015, November 18). Retrieved January 20, 2017, from ww2.kqed.org/learning/2015/11/18/is-storing-health-care-data-in-the-cloud-a-good-idea
51 - Strickland, M., & Barrett, Y. (2016, October 12). The Shifting Role of Patients In Today’s Healthcare System: Introducing Changemaker Health (S. Jefferson, Ed.). Retrieved from ashoka.org/en/story/shifting-role-patients-today%E2%80%99s-healthcare-system-introducing-changemaker-health52 - Who is considered a Health Care Provider/Practitioner? (n.d.). Retrieved December 1, 2016, from hr.berkeley.edu/node/377753 - Shipper, E. S., MD, Hardaway, J. C., MD, PHD, Garvey, E. M., MD, & Logghe, H., MD. (2016). Talking through time: Trends in communication and the evolving patient-physician relationship. Bulletin of the American College of Surgeons. Retrieved from bulletin.facs.org/2016/08/trends-in-communication-and-the-evolving-patient-physician-relationship54 - Improving Healthcare Quality: The Path Forward, 113th Cong. (2013) (testimony of Mark B. McClellan).55 - Pharmaceutical Industry Profile [PDF]. (2010, July). Washington, DC: Office of Health and Consumer Goods, International Trade Administration, United States Department of Commerce.56 - Pharmaceutical Research and Manufacturers of America. (n.d.). Retrieved from phrma.org/about/our-mission57 - Addressing Market Distortions [PDF]. (2016, March). Washington, DC: Pharmaceutical Research and Manufacturers of America.58 - Modernizing Drug Discovery, Development and Approval [PDF]. (2016, March). Washington, DC: Pharmaceutical Research and Manufacturers of America.59 - Labrien, D. (2016, October 3). The 3 Key Challenges Health Tech Startups Face Today. Retrieved from tech.co/key-challenges-health-tech-startups-2016-10
Mechanisms for Driving Quality
Meet the Stakeholders
Now Next
46 - CONCLUSION
QUALITY TREND REPORT 2017
81 - Leventhal, R. (2016, December 16). With Passage of the 21st Century Cures Act, Interoperability Moves to the Front Lines. Retrieved January 21, 2017, from healthcare-informatics.com/article/interoperability/passage-21st-century-cures-act-interoperability-moves-front-lines82 - Mobile Data Security and HIPAA Compliance. (2015). Retrieved January 20, 2017, from hipaajournal.com/mobile-data-security-and-hipaa-compliance83 - Slabodkin, G. (2017, January 4). Data Silos Holding Back Healthcare Breakthroughs, Outcomes. Retrieved January 18, 2017, from healthdatamanagement.com/news/data-silos-holding-back-healthcare-breakthroughs-outcomes84 - Open Connectivity Foundation. (n.d.). Retrieved January 14, 2017, from openconnectivity.org85 - Shipper, E. S., MD, Hardaway, J. C., MD, PHD, Garvey, E. M., MD, & Logghe, H., MD. (2016). Talking through time: Trends in communication and the evolving patient-physician relationship. Bulletin of the American College of Surgeons. Retrieved from bulletin.facs.org/2016/08/trends-in-communication-and-the-evolving-patient-physician-relationship86 - 2016 Connected Patient Report Insights into patient preferences on telemedicine, wearables and post-discharge care (Rep.). (2016). Retrieved January 15, 2017, from secure2.sfdcstatic.com/assets/pdf/industries/2016-state-of-the-connected-patient.pdf87 - Bendix, J. (2015, February 26). From quantity to quality: Meeting the new demands of value-based care. Retrieved from medicaleconomics.modernmedicine.com/medical-economics/news/quantity-quality-meeting-new-demands-value-based-care?page=full88 - The Affordable Care Act: A Brief Summary [PDF]. (2011). Wash: National Conference of State Legislatures.89 - H.R.34 - 114th Congress (2015-2016): 21st Century Cures Act. (2016). Congress.gov. Retrieved 31 March 2017, from congress.gov/bill/114th-congress/house-bill/34/text
USM/032717/0003 - MCM/032717/0022