title: Improving Oncology Quality Measurement in Accountable Care: Filling Gaps with Cross-Cutting Measures.
abstract: Payment for health care services, including oncology services, is shifting from volume-based fee-for-service to value-based accountable care. The objective of accountable care is to support providers with flexibility and resources to reform care delivery, accompanied by accountability for maintaining or improving outcomes while lowering costs. These changes depend on health care payers, systems, physicians, and patients having meaningful measures to assess care delivery and outcomes and to balance financial incentives for lowering costs while providing greater value. Gaps in accountable care measure sets may cause missed signals of problems in care and missed opportunities for improvement. Measures to balance financial incentives may be particularly important for oncology, where high cost and increasingly targeted diagnostics and therapeutics intersect with the highly complex and heterogeneous needs and preferences of cancer patients. Moreover, the concept of value in cancer care, defined as the measure of outcomes achieved per costs incurred, is rarely incorporated into performance measurement. This article analyzes gaps in oncology measures in accountable care, discusses challenging measurement issues, and offers strategies for improving oncology measurement. 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.
  
  
  BACKGROUND
  Funding for this project was provided by the National Pharmaceutical Council (NPC). Westrich and Dubois are employees of the NPC. Valuck is a partner with Discern Health. Blaisdell and Dugan are employed by Discern Health. McClellan reports fees for serving on the Johnson & Johnson Board of Directors. Dugan reports consulting fees from the National Committee for Quality Assurance and Pharmacy Quality Alliance. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Study concept and design were contributed by Blaisdell, Valuck, Dugan, and Westrich. Blaisdell took the lead in data collection, along with Valuck and Dugan, and data interpretation was performed by Valuck, Blaisdell, Westrich, and Dubois. The manuscript was written by Blaisdell, along with Valuck and Dugan, and revised by Valuck, Westrich, Miller, and McClellan.
authors.affiliation: 1 Discern Health, Baltimore, Maryland.
authors.forename: Tom
authors.initials: T
authors.lastname: Valuck
authors.affiliation: 1 Discern Health, Baltimore, Maryland.
authors.forename: David
authors.initials: D
authors.lastname: Blaisdell
authors.affiliation: 1 Discern Health, Baltimore, Maryland.
authors.forename: Donna P
authors.initials: DP
authors.lastname: Dugan
authors.affiliation: 2 National Pharmaceutical Council, Washington, DC.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Westrich
authors.affiliation: 2 National Pharmaceutical Council, Washington, DC.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Dubois
authors.affiliation: 3 American Society of Clinical Oncology, Alexandria, Virginia.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Miller
authors.affiliation: 4 Duke-Margolis Center for Health Policy, Durham, North Carolina.
authors.forename: Mark
authors.initials: M
authors.lastname: McClellan
mesh_terms: D003695:Delivery of Health Care / Q000191:economics*; D018588:Fee-for-Service Plans / Q000191:economics; D006296:Health Services / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D008495:Medical Oncology / Q000191:economics*; D010604:Pharmacy; D058996:Quality Improvement / Q000191:economics*; D011787:Quality of Health Care / Q000191:economics*