Kimberly Westrich

This study assesses how ACOs optimize medication use, whether there is an association between efforts to optimize medication use and achievement on financial and quality metrics, organizational factors that correlate with optimized medication use, and barriers to optimized medication use. Results were gathered from a survey as well as qualitative interviews to collect information on perceptions of ACO leadership. The study builds on NPC’s previous research with the American Medical Group… Show more

This study assesses how ACOs optimize medication use, whether there is an association between efforts to optimize medication use and achievement on financial and quality metrics, organizational factors that correlate with optimized medication use, and barriers to optimized medication use. Results were gathered from a survey as well as qualitative interviews to collect information on perceptions of ACO leadership. The study builds on NPC’s previous research with the American Medical Group Association and Premier, Inc., on ACO readiness to provide updated data points on ACO success.

Compared to NPC’s previous research:

- more ACOs give themselves higher scores on educating patients about alternatives when determining the recommended medication, which is significant given that patient education is a pending Centers for Medicare and Medicaid Services metric.
- more ACOs are involving pharmacists in direct patient care, and focus on appropriate generic use has also been expanded.
- more ACOs identify and notify care providers of potential adverse events, alert providers to gaps in preventive care, and electronically transmit prescriptions for non-controlled substances than in the previous study.

This research indicates medication use practices may be easier to implement if ACOs provide access to data to both pharmacists and physicians, focus on removing technological barriers, gather buy-in from frontline physicians and integrate pharmacists into care teams. Policies that remove barriers to or incentivize integration of practices to optimize medication use—and integrate pharmacists into care delivery—are likely to improve medication use in ACOs, which should enhance achievement of the “Triple Aim” of improving the individual experience of care, improving the health of the population, and reducing per capita costs for care. Show less

In the summer of 2016, the Turning the Tide Against Cancer initiative convened a working group comprised of a multidisciplinary group of stakeholders to come to consensus around a set of best practices for oncology clinical pathways that balance innovation with patient access. The project also included an assessment of select pathways and pathway programs to determine how closely they align with the identified best practices. This article focuses on the assessment and outlines four key findings… Show more

In the summer of 2016, the Turning the Tide Against Cancer initiative convened a working group comprised of a multidisciplinary group of stakeholders to come to consensus around a set of best practices for oncology clinical pathways that balance innovation with patient access. The project also included an assessment of select pathways and pathway programs to determine how closely they align with the identified best practices. This article focuses on the assessment and outlines four key findings about how pathways affect patient care:

- There is little transparency to help patients understand how pathways are developed and modified, how payers and developers choose specific regimens for inclusion in their pathway, and whether and how payers and developers consider cost to designate on-pathway versus off-pathway treatments.

- Pathway developers frequently do not engage patients in pathway development and maintenance and instead see patient engagement as an “after-the-fact” responsibility of providers.

- Pathways can potentially interfere with the patient–provider decision-making process. Providers and health care teams may face redundant workflows due to managing multiple pathways. This is exacerbated by a lack of interoperability and integration between the pathway's IT infrastructure and the patient's electronic medical record (EMR), all of which add to provider burden at the point of care.

- There remains a significant lack of accountability, particularly to patients, for the quality, effectiveness, and transparency of pathways. Show less

Using Medicare Expenditure Panel Survey data (1996-2013), this study estimated the long-run average cost (LAC) for an average pharmaceutical, accounting for the effects of generic competition and medical cost offsets.

Takeaway points:
- Focusing on branded drug prices may significantly overstate the LAC.
- Accounting for patent expiration, the loss of exclusivity price and the launch price overstate the LAC by 39% and 11%, respectively, and the LAC net of medical cost offsets by… Show more

Using Medicare Expenditure Panel Survey data (1996-2013), this study estimated the long-run average cost (LAC) for an average pharmaceutical, accounting for the effects of generic competition and medical cost offsets.

Takeaway points:
- Focusing on branded drug prices may significantly overstate the LAC.
- Accounting for patent expiration, the loss of exclusivity price and the launch price overstate the LAC by 39% and 11%, respectively, and the LAC net of medical cost offsets by 75% and 40%, respectively.
- To ensure that all drugs providing long-run value end up entering the marketplace, value assessments or related market access decisions should consider these long-term costs. Show less

Building on a prior case study analysis by the Lewin Group, National Pharmaceutical Council (NPC) researchers conducted cross-framework comparisons of multiple myeloma assessments using value assessment frameworks from the American Society of Clinical Oncology (ASCO), the Institute for Clinical and Economic Review (ICER), the Memorial Sloan Kettering Cancer Center (DrugAbacus), and the National Comprehensive Cancer Network (NCCN), and examined the consistency of findings across three case… Show more

Building on a prior case study analysis by the Lewin Group, National Pharmaceutical Council (NPC) researchers conducted cross-framework comparisons of multiple myeloma assessments using value assessment frameworks from the American Society of Clinical Oncology (ASCO), the Institute for Clinical and Economic Review (ICER), the Memorial Sloan Kettering Cancer Center (DrugAbacus), and the National Comprehensive Cancer Network (NCCN), and examined the consistency of findings across three case studies.

Although one might expect the various multiple myeloma value assessments to arrive at generally consistent results, this study indicates that consistency varied across our case studies. Only a third of the assessment results were clearly consistent. Areas of inconsistency included conflicting efficacy and toxicity assessments, as well as differing interpretations of the quality of the clinical evidence. For some areas, consistency could not be determined due to a lack of transparency around methods and evidence, or due to incomparable measures of cost.

Researchers suggested two key opportunities to improve the quality and utility of value assessment frameworks:

Transparency impacts the reproducibility and interpretation of assessment results. Full transparency on the specific body of evidence underlying an assessment, how various pieces of that evidence drove an assessment’s results, the process by which the evidence was transformed into components of the assessment, and the actual values of those components would enhance the accessibility and credibility of value framework assessments.

Usability of the frameworks can be improved by ensuring assessment results are fit-for-purpose and providing more information on how to interpret and use the results. Guidance on using the results should also extend to who the appropriate users are, as payer-focused assessments may be misleading for patients and vice versa. Show less

Discern Health analyzed gaps in accountable care measure sets for 10 cancer conditions that were selected based on incidence and prevalence; impact on cost and mortality; a diverse range of high-cost diagnostic procedures and treatment modalities (e.g., genomic tumor testing, molecularly targeted therapies, and stereotactic radiotherapy); and disparities or performance gaps in patient care. We identified gaps by comparing accountable care set measures with high-priority measurement… Show more

Discern Health analyzed gaps in accountable care measure sets for 10 cancer conditions that were selected based on incidence and prevalence; impact on cost and mortality; a diverse range of high-cost diagnostic procedures and treatment modalities (e.g., genomic tumor testing, molecularly targeted therapies, and stereotactic radiotherapy); and disparities or performance gaps in patient care. We identified gaps by comparing accountable care set measures with high-priority measurement opportunities derived from practice guidelines developed by the National Comprehensive Cancer Network and other oncology specialty societies. We found significant gaps in accountable care measure sets across all 10 conditions. For each gap, we searched for available measures not already being used in programs. Where existing measures did not cover gaps, we recommended refinements to existing measures or proposed measures for development.

We shared the results of the measure gap analysis with a roundtable of national experts in cancer care and oncology measurement. During a web meeting and an in-person meeting, the roundtable reviewed the gap analysis and identified priority opportunities for improving measurement. The group determined that overreliance on condition-specific process measures is problematic because of rapidly changing evidence and increasing personalization of cancer care. The group’s primary recommendation for enhancing measure sets was to prioritize and develop effective cross-cutting measures that assess clinical and patient-reported outcomes, including shared decision making, care planning, and symptom control. The group also prioritized certain safety and structural measures to complement condition-specific process measures. Further, the group explored strategies for using clinical pathways and devising layered measurement approaches to improve measurement for accountable care. This article presents the roundtable’s conclusions and recommendations for next steps. Show less

This paper describes, compares, and contrasts key characteristics such as intended purposes, development processes, methods, and the elements of value (benefits and costs) for the following value assessment frameworks:

► The American College of Cardiology and the American Heart Association (ACC-AHA) Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures
► The American Society of Clinical Oncology's (ASCO) Conceptual Framework to Assess the Value… Show more

This paper describes, compares, and contrasts key characteristics such as intended purposes, development processes, methods, and the elements of value (benefits and costs) for the following value assessment frameworks:

► The American College of Cardiology and the American Heart Association (ACC-AHA) Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures
► The American Society of Clinical Oncology's (ASCO) Conceptual Framework to Assess the Value of Cancer Treatment Options
► The Institute for Clinical and Economic Review (ICER) Value Framework Memorial Sloan Kettering Cancer Center's DrugAbacus
► The National Comprehensive Cancer Network's (NCCN) Evidence Blocks.

The paper delves deeper into the rather disparate frameworks by comparing and contrasting key characteristics such as their intended purposes, development processes, methods, and the elements of value (benefits and costs).

Six broad categories were identified for analysis in this paper: the framework development process, measures of benefit, measures of cost, methodology, evidence, and the framework assessment process. Within each category, key components for evaluation are identified. Show less

This case study highlights the critical components of Sharp Rees-Stealy Medical Group's electronic medication refill system that allows for a centralized team to manage all incoming prescription requests. The case study demonstrates how pharmacists can help offset primary care providers' (PCPs) workload, as PCPs take on additional population health management tasks in ACOs.

Five annual surveys of healthcare decision-makers potentially affected by comparative effectiveness research (CER) indicate sustained recognition of its importance and potential impact. Initial expectations of immediate CER impact have over time turned to stakeholder assessments of little short-term impact. In successive surveys, they project a continuous horizon of 3-5 years for CER to have a moderate or substantial improvement in decision making. The prominence of Patient-Centered Outcomes… Show more

Five annual surveys of healthcare decision-makers potentially affected by comparative effectiveness research (CER) indicate sustained recognition of its importance and potential impact. Initial expectations of immediate CER impact have over time turned to stakeholder assessments of little short-term impact. In successive surveys, they project a continuous horizon of 3-5 years for CER to have a moderate or substantial improvement in decision making. The prominence of Patient-Centered Outcomes Research Institute in CER is highlighted by stakeholders, but greater emphasis on translating and disseminating research findings is needed, a role in which Agency for Healthcare Research and Quality is expected to contribute. Stakeholders, including patients, must be engaged throughout to ensure that findings provide the flexibility for decision makers to apply them to their patient populations. Show less

Care pathways are developed to manage patient care, improve quality, reduce variation, and increase efficient use of healthcare. They provide a mechanism for integrating evidence-based medicine into clinical practice. However, formal best practices to guide development, implementation, evaluation, and monitoring are needed.
► Often, pathways are implemented to manage drug utilization, particularly specialty drugs.
► Trends in development and implementation have not been investigated… Show more

Care pathways are developed to manage patient care, improve quality, reduce variation, and increase efficient use of healthcare. They provide a mechanism for integrating evidence-based medicine into clinical practice. However, formal best practices to guide development, implementation, evaluation, and monitoring are needed.
► Often, pathways are implemented to manage drug utilization, particularly specialty drugs.
► Trends in development and implementation have not been investigated systematically.
► Pathways will have more influence in the future, particularly with bundled or episode-based payments.
► Research findings support implementation of standards and increased transparency in all dimensions of pathway development, implementation, and evaluation.
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Measurement in accountable care programs is essential for promoting quality improvement and balancing financial incentives, but gaps in measurement can result in missed opportunities to improve patient care and health systems.

This peer-reviewed study, “Solutions for Filling Gaps in Accountable Care Measure Sets,” explores measurement gaps for high-priority conditions and identifies ways to improve measure sets.