Value assessment in general, and the use of cost-effectiveness in particular, is receiving renewed interest as a tool for controlling health care spending. Currently, the most common method for determining incremental cost-effectiveness of healthcare interventions is based on a calculation of quality-adjusted-life-years (QALYs). While the model has a basic appeal for making population-level decisions (by reducing patient populations to single, aggregate numeric values), it also poses several significant concerns from the vantage point of patient-centeredness and efforts to preserve access to needed care for individual patients and people with disabilities. Of particular concern to me are the implications of use of QALYs for discrimination against people with disabilities, and its conflicting goals from the goals of personalized medicine.
The health care system is moving to models that seek to pay for value. In January 2015, the U.S. Department of Health and Human Services (HHS) accelerated the movement towards value-based payments by setting a goal to shift 50 percent of Medicare fee-for-service payments to alternative payment models (APMs) by 2018.1 The Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS) is playing a significant role in advancing value-based or alternative payment models. In addition, many State health agencies and private payers are exploring similar changes. However, CMMI and other payers lack sound procedures and standards for patient-centeredness. Patient-centered approaches to value-based payment are needed to ensure that new payment models support value that matters to patients. To get it right, patient engagement is essential.
Value frameworks and similar value assessment tools are playing an increasingly prominent role in health care as insurance companies, Medicare, state agencies, and other stakeholders all are working rapidly toward "value-based" payment models. But will they pay for care that patients value? The Partnership to Improve Patient Care (PIPC) was founded on principles of patient-centeredness that cannot be achieved without engaging patients and people with disabilities. For the transition to a value-based health system to achieve outcomes that matter to patients, patients must have a seat at the table in defining value through the development of the value frameworks and tools.
Today, the Partnership to Improve Patient Care (PIPC) released a new White Paper on patient-centeredness in alternative payment models (APMs). This White Paper represents an important step in PIPC’s discussion of the application of comparative effectiveness research, and should serve as an important tool for policymakers in considering the future of value-based payment models
The issue of how to set priorities for comparative research and health technology assessment has long been recognized as an important one. The statute creating the Patient-Centered Outcomes Research Institute (PCORI) also recognized this, describing specific factors and procedural considerations for defining national priorities for research. The question of how best to define research priorities, and whether to do so by proactively identifying specific topics or issuing broader solicitations for investigator-initiated prioritization, has been an area of ongoing debate.
Three years into the creation of the Patient-Centered Outcomes Research Institute (PCORI) under the Affordable Care Act, the Partnership to Improve Patient Care (PIPC) embarked on a mission to evaluate PCORI’s progress in meeting its statutory mandate to prioritize, conduct, and communicate comparative effectiveness research (CER) in ways that are patient-centered – or to quote PCORI, identify what it means to do “research done differently.” Our analysis, as outlined in a new white paper, focuses on a number of issues pertaining to PCORI including: patient centeredness, patient engagement, research methods, research priorities, advisory panels, research dissemination, evaluation, and funding.
In light of PCORI’s mandate to conduct comparative clinical effectiveness research, CER communication tools and materials should present patients with sound, clinical evidence to help inform their individual decision-making process. Based on the focus on patient care management found in PCORI’s research agenda, is it clear that the communication of the results of that research will have a direct impact on individual patient decision-making. Therefore, as PCORI begins to play a more active role in CER communication, PIPC believes these proposed best practices represent elements for all CER organizations to consider when communicating CER results to physicians and patients. While this document reflects extensive research and engagement with the patient and provider communities, we also consider it to be a living document that will continue to evolve based on feedback we receive.
This White Paper inventories and discusses the basic elements of the framework for CER that are identified in PPACA and compares these requirements to current procedures developed and used by the Agency for Healthcare Research and Quality (AHRQ) to conduct CER through its Effective Health Care Program and through the funding provided by the American Recovery and Reinvestment Act. Finally, the paper identifies issues related to these elements to monitor as implementation of PCORI gets underway in the coming months.
This paper inventories and discusses the basic elements of the framework for comparative clinical effectiveness research that are identified in PPACA: requirements for stakeholder participation in comparative clinical effectiveness research; requirements for transparency in procedures and operations; requirements for public opportunity to comment on research priorities and to be engaged in Patient-Centered Outcomes Research Institute (PCORI) review processes; and requirements for open decision-making processes. This paper also compares these requirements to current procedures developed and used by the Agency for Healthcare Research and Quality (AHRQ) to conduct comparative effectiveness research through its Effective Health Care Program and through the funding provided by the American Recovery and Reinvestment Act (ARRA).