A Step toward Measuring High-Value Care for Patients with Complex Chronic Disease

As health care moves forward in defining a system of accountable and valued care, aligning health care cost inflation with overall economic growth, and ensuring access to appropriate evidence-based services for all, physicians are being called upon to break down many barriers to achieving accountable valued care. These include right-sizing our outsized delivery system, correcting unwarranted variations in care, decreasing unnecessary health care spending, and improving patient-centered outcomes.

Part of this effort involves decreasing the escalating costs of Medicare and the variations in approaches and costs of care at the end of life. To help us reach these goals, the Centers for Medicare & Medicaid Services (CMS) continues to redefine the Physician Fee Schedule (PFS), strengthening the link to quality outcomes. Following this strategic path, CMS is increasingly focusing on patient-important outcomes (i.e., 30-day readmissions, mortality, patient safety indicators, hospital-acquired conditions) and efficiency of care in the inpatient setting, placing greater weight on clinical outcomes measures.

When we look at the hospital value-based purchasing (VBP) domains and trends in their weighting forecasts, we are beginning to see similar changes in the outpatient arena of patient care. In 2013, clinical processes accounted for 70 percent of hospital VBP scores, with patients’ experience making up the remaining 30 percent. Patient outcomes measures were introduced to the VBP measurements in 2014, accounting for 25 percent of the overall score and decreasing the clinical process domain to 45 percent. In 2015, CMS included measures of efficiency (20 percent domain weight) while increasing the weight of care outcomes to 30 percent, maintaining patient experience at 30 percent and decreasing clinical process measures to only 20 percent. In 2016, the clinical process domain weight will be further decreased to only 10 percent of VBP scores, with patient outcomes increasing to 40 percent and efficiency and patient experience each accounting for 25 percent of the overall score. This reflects the trend toward measuring the value of care delivered (value = quality–safety–service/cost). This trend is also evident in the ESRD Quality Incentive Program measures for 2016, decreasing the number of report-only measures to three and increasing the clinical outcomes measures from six to eight.

The PFS final rule summary for 2016 is quite interesting in that it also reflects the emphasis on patient-centric outcome metrics and the shift away from reporting/process metrics. Moreover, it includes changes that will affect patient-important aspects of managing complex chronic disease such as CKD and that will help physicians and their care teams decrease the variations and cost seen now with end-of-life care, better meet patients’ health care goals, and respect patients’ preferences.

In 2016, the PFS includes a reimbursement for advanced care planning without exclusion of providers paid under the ESRD monthly capitation payment. By adding these steps in the care of our patients to a reimbursement plan, CMS recognizes the significance of shared decision-making and patient-focused end-of-life care—a step to achieving high-value care. To complement this, the Physician Quality Reporting System metrics will include referral to hospice for adults with kidney disease. Furthermore, to decrease the burden of documentation and reporting measures that do not lead to improved quality, as recommended by the American Society of Nephrology, CMS removed two measures under adult kidney disease: 1) hemodialysis adequacy solute measure and 2) the hemodialysis vascular access decision-making by surgeons measure.

Another step in eliminating barriers to delivering high-value care is the addition of a home dialysis Current Procedural Terminology code to bill for virtual (telemedicine) care visits. This will be particularly helpful in meeting the qualifications for home dialysis programs and in facilitating timely input from expertise in nephrology to care and education for patients in distant rural areas, or regions without ready access to nephrologists or nephrology care teams. These changes to the PFS, which support the importance of long-term care management for complex chronic diseases such as advanced kidney disease, are important steps in facilitating the delivery of patient-centered, valued specialty care, possibly leading to a decrease in variations in care by allowing knowledge sharing and continuity of care across distances.

As delivery of health care moves toward alternative payment models, nephrology as a profession and nephrologists as knowledge experts are highly experienced in creating care teams to achieve quality, safety, and service goals. After all, we were involved in the first CMS-directed pilot of VBP/pay for performance and bundled care payment with the ESRD Quality Incentive Program and Prospective Payment System, and now a select few are stepping into the ESRD seamless care organization pilot.

As the US population ages and the survival of those with complex chronic diseases and multiple comorbidities increases, our experience and expertise will allow us to lead the way in defining successful management of this “top of the pyramid,” medically complex population. Our challenge, as care models evolve to reward quality and patient-centered care, will be to thoughtfully evaluate best practices throughout the disease trajectory of CKD in a scholarly manner and to inform the medical community, payers, and patients about how to better define and recognize truly value-based care for medically complex chronic disease.