Genentech Quality Trend Report · 31/03/2017 · The 2017 Genentech Quality Trend Report...

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

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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



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



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 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.



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



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.



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


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


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


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


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


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


• 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:


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


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


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



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


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



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.

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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


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

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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

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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


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

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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

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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

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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


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

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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


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


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

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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


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


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


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

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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


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


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



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



REFERENCES

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Introduction Evolution of Quality in the US

Definitions



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Mechanisms for Driving Quality

Meet the Stakeholders

Now Next

46 - CONCLUSION


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