On April 19, 2017, I provided comments to the Centers for Medicare and Medicaid Innovation (CMMI) on behalf of the Partnership to Improve Patient Care (PIPC) related to some new, recently proposed episode payment models. I applauded the agency for making a deliberate and conscious effort to solicit authentic patient feedback about their proposed new payment models. Although I’ve been critical in the past, I told them that I appreciated their seizing of this opportunity to forge a new path forward on engaging stakeholders, particularly patients, in the development, implementation and evaluation of alternative payment models.
Last December, PIPC issued a report entitled, “A Roadmap to Increased Patient Engagement at CMMI” to serve as a reference for engagement practices. In reviewing CMMI’s engagement strategies, we found that a number of its programs featured limited stakeholder involvement and transparency. A core concern of ours is that the agency has not developed criteria for patient-centeredness nor an infrastructure for patient engagement, leading to significant concerns about the leap to mandatory models. On the contrary, we believe that the establishment of meaningful criteria would provide a structured patient-focused framework to guide the agency’s work. Patients should be engaged in developing patient-centeredness criteria and ensuring they are applied to the work of the Innovations Center. As specified in statute, demonstrations should be evaluated against these criteria. By doing so, CMMI can build an infrastructure for patient engagement that goes beyond a mere notice and comment period and instead incorporates real mechanisms for achieving care that patients value.
In order to align with care that patients value, it is imperative that alternative payment models incorporate high-quality decision aids to mitigate the potential for driving “one-size-fits-all” care. Patient groups are prioritizing the development of shared decision-making tools, informed by their work to identify and reach patients from whom we can learn about the real-world impact of treatments. And patients need the ability to make informed choices about their care so that we are not wasting health care resources on treatments that don’t achieve what the patient wants. While the program for shared decision-making in accountable care organizations currently underway at CMMI is a good start, the agency should develop standards for shared decision-making that assure their implementation in a manner that is transparent, understandable to patients, and broadly disseminated for use. High quality shared decision-making should be a core component of all new models going forward.
By contrast, policies that seek to standardize care in a manner that has the potential to limit patient access to care that is suited to their needs, preferences and outcomes only serve to hinder the promise of personalized medicine. Medicare beneficiaries are not a homogenous population. Patients have varying levels of functionality; some continue to be runners or play sports, while others may be less active. Therefore, it is vital that the device or treatment chosen for each beneficiary be appropriately suited to their personal needs, preferences and outcomes. It is also imperative that patients in alternative payment models or other demonstrations are provided access to protections, such as a rapid appeals process or access to an ombudsman, that would allow for a more individualized approach to their care.
Engaging the patient community is a complex task that requires more than the notice and comment processes traditionally used by regulatory agencies. However, a more structured process for patient engagement that leverages CMMI’s own best practices, along with creative methods employed by organizations such as the Patient-Centered Outcomes Research Institute (PCORI) and the Food and Drug Administration’s Patient Focused Drug Development Initiative, will ensure that the patient perspective is well represented in CMMI’s model tests and improve their likelihood of success.
With patient engagement, we look forward to the introduction of new models with support and buy-in from the impacted patient communities that will be integral to their success.
In order to align with care that patients value, it is imperative that alternative payment models incorporate high-quality decision aids to mitigate the potential for driving “one-size-fits-all” care. Patient groups are prioritizing the development of shared decision-making tools, informed by their work to identify and reach patients from whom we can learn about the real-world impact of treatments. And patients need the ability to make informed choices about their care so that we are not wasting health care resources on treatments that don’t achieve what the patient wants. While the program for shared decision-making in accountable care organizations currently underway at CMMI is a good start, the agency should develop standards for shared decision-making that assure their implementation in a manner that is transparent, understandable to patients, and broadly disseminated for use. High quality shared decision-making should be a core component of all new models going forward.
By contrast, policies that seek to standardize care in a manner that has the potential to limit patient access to care that is suited to their needs, preferences and outcomes only serve to hinder the promise of personalized medicine. Medicare beneficiaries are not a homogenous population. Patients have varying levels of functionality; some continue to be runners or play sports, while others may be less active. Therefore, it is vital that the device or treatment chosen for each beneficiary be appropriately suited to their personal needs, preferences and outcomes. It is also imperative that patients in alternative payment models or other demonstrations are provided access to protections, such as a rapid appeals process or access to an ombudsman, that would allow for a more individualized approach to their care.
Engaging the patient community is a complex task that requires more than the notice and comment processes traditionally used by regulatory agencies. However, a more structured process for patient engagement that leverages CMMI’s own best practices, along with creative methods employed by organizations such as the Patient-Centered Outcomes Research Institute (PCORI) and the Food and Drug Administration’s Patient Focused Drug Development Initiative, will ensure that the patient perspective is well represented in CMMI’s model tests and improve their likelihood of success.
With patient engagement, we look forward to the introduction of new models with support and buy-in from the impacted patient communities that will be integral to their success.
