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Barriers to the Implementation of Patient-Reported Outcome Based Performance Measures for Assessing Quality

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The pressure to constrain healthcare costs, maximize clinical quality and improve patient experience has stimulated new approaches to measuring value, and places greater focus on the use of patient-reported outcome (PRO) based performance measures.
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PRO-PMs provide meaningful insight into outcomes, experiences, and engagement from the patient perspective. As healthcare continues to shift toward models of reimbursement that put the provider at-risk for financial performance, patient-focused measures become increasingly important.

Examples of current PRO-based performance measures address the following aspects of care:

1) health-related quality of life (including functional status)

2) symptoms and symptom burden (e.g., pain, fatigue)

3) experience with care

4) behavior change (e.g., smoking, diet, exercise)

5) shared decision making.

The use of these measures in emerging payment and delivery models is expected to improve communication between the healthcare professional and patient, and ultimately outcomes, throughout all aspects of care.

Given the growing importance and timeliness of PRO-PMs, Avalere Health convened a group of experts to participate in a multi-stakeholder Dialogue series, Advancing Patient-Reported Outcome Performance Measures in New Payment and Delivery Models. The two-part Dialogue identified policy solutions to advance the appropriate use of PRO-PMs in existing and future payment and delivery models. At the first meeting, stakeholders discussed challenges that may arise as a result of integrating new PRO-PMs into new models of care.

Some of the challenges highlighted include:

1. Existing PRO measures were Not Designed to be PRO-PMs

Use of PRO-PMs (as distinct from PROs used as endpoints in clinical research) has yet to gain widespread endorsement due to concerns about lack of clinical, patient, population and programmatic relevance. Existing PRO measures focus on measuring outcomes at a patient level to assess health status or change over time. These PRO measures were not developed as performance measures designed to help organizations and providers internally improve or assess comparative performance. PRO measures designed to capture outcomes at the individual level must be properly translated into PRO-PMs used at an organizational level.

2. Need for a Balance between Condition Specific versus non-Condition Specific PRO-PMs

There are two types of PRO-PMs — condition-specific (e.g., PMs based on the PHQ-9 for depression) versus condition agnostic (e.g., PMs based on the SF-36); both demonstrate a unique value. As the system tries to iron out what the right balance is between condition-specific and non-specific measures, patients may be faced with the undue burden of completing redundant surveys, as providers likely face increased administrative burden. These pressures only multiply when a patient has multiple co-morbidities.

3. Today’s PRO-PMs Are Not Synchronized or Harmonized with Ongoing Measurement Activities

Activity in the PRO measurement space began decades ago and gained interest in the performance measurement space around 2010 with the passage of the Affordable Care Act. Despite considerable multi-stakeholder investment in PRO measurement, there has been little investment in PRO-PM development; as PRO-PMs continue to be developed, synchronization across settings of care must be prioritized and harmonization across the use of PRO-PMs must be considered.

4. Feedback Loops to Assess the Value of PRO-PMs Are Not Currently In Place

We cannot effectively evaluate PRO-PMs for appropriateness (e.g., Does the PRO-PM provide information relevant to stakeholder decisions?) and impact (e.g., Did the PRO-PM result in improved delivery of care?) without feedback loops that stimulate a continuously learning healthcare system. This involves aggregating PRO data from different levels of the healthcare system, providing feedback to providers and results to patients, training clinical staff, and utilizing interoperable EHR systems. Designing these feedback loops will require resources and coordination; however, they are critical to evaluating PRO-PMs that drive quality and performance improvement.

The second meeting in this two-part series, which took place in the Summer of 2014 continued this conversation by identifying policy solutions that respond to the potential use of PRO measures in new payment and delivery models. Avalere Health, along with the co-sponsors, will release a white paper addressing the challenges and opportunities associated with integrating PRO-PMs into new models of care. The sponsors of this important initiative are hoping to publish findings by the end of 2014 that provide a roadmap for integrating PRO-PMs in new payment models.

This story was created in collaboration with The American Cancer Society-Cancer Action Network, Families USA, the Kaiser Permanente Institute for Health Policy, the National Quality Forum, the Pacific Business Group on Health, and the Pharmaceutical Research and Manufacturers of America.

For any PRO-PM related questions, reach out to Nelly Ganesan at

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