The three long-standing tenets of value-based care are: excellent quality of care, at a lower cost, all while improving the patient’s experience. Historically, most value-based insurance plan design revolves around quality, cost, and utilization drivers. But the third tenant, improving the patient’s experience, has been more difficult to quantify. From surveys to focus groups, attaching savings to patient experience is difficult to track and mostly subjective. How can insurance plans and providers capture the patient experience? Is there a way to incorporate feedback into value contracts in both an accurate and meaningful way?
Patient surveys have been around since 1995 when the Agency for Healthcare Research and Quality (AHRQ) at the Department of Health and Human Services (HSS) created the Consumer Assessment of Healthcare Providers and Systems (CAHPS) suite of surveys. Only more recently has the Centers for Medicare and Medicaid Services (CMS) put an increased emphasis on these surveys and their outcomes.
Why Patient Experience?
At its core, value-based care is about helping the patient. Medical care should be patient-centric, aligning with patients’ wants, needs, and preferences. Understanding patient experience is a key step in moving toward patient-centric care. And just as with any other services organization, the patient’s experience of a visit should carry weight and direct change. The patient-provider experience will drive a patient’s engagement and could ultimately lead to better health outcomes. A trusted relationship is vital and accurately understanding the range of interactions that patients have with the healthcare system is a critical piece. But challenges exist when measuring patient experience, in part, because it is a complex concept to accurately capture.
CAHPS in Medicare Shared Savings Program
For many years, within the Medicare Shared Savings Program (MSSP), CAHPS surveys were one portion of the quality measures that each Accountable Care Organization (ACO) was mandated to report. These measures require ACOs to hire an approved survey vendor to send out surveys to a very small sampling of the patients attributed to the ACO during the last few months of the year, with hopes that some would respond. But replies have been sparse and beneficiary understanding of the ACO lacking. It is hard for patients to differentiate between a visit to an ACO doctor versus any other doctor. And because the survey vendors are only allowed to collect survey responses annually between October and January, some patients cannot recall their visit that may have occurred several months prior. This can lead to inaccurate or subjective reporting which can adversely affect the ACO’s performance.
The purpose of the patient survey is to improve the patient experience and the patient/provider relationship. This requires open lines of communication between a patient and provider. The CAHPS survey does help facilitate that, but most ACOs receive the results almost a year after the performance period, with no way to incorporate changes based on feedback. To enhance the patient’s experience, it would be more helpful to employ real-time feedback from the patients, enabling providers to enact change based on responses. Many health systems already incorporate some type of patient survey immediately after visits. Health systems could combine efforts and use that information to fulfill what is needed for CAHPS for MIPS. As it stands, the CAHPS for MIPS survey is required but unable to provide actionable data to impact lasting change.
What works better to gather meaningful feedback from patients and incorporate change are patient panels or forums. Taking the time to pull a group of patients together to discuss what goes well and what does not go well within the doctor’s office visit provides valuable insight. Patients need to know they have an advocate listening to their concerns and proactively promoting change. We do not want to ask for feedback that will not be used. Instead, CHESS wants to focus on what changes we can make within our ACO to improve the quality of care for all patients.
As CHESS has spent time interviewing our Medicare beneficiaries who serve on our ACO’s Board of Managers, we have uncovered opportunities related to patient care. These important insights, such as accessibility issues and confusion around Annual Wellness Visits, could not have been captured from a patient survey. CHESS plans to address these opportunities within the ACO and partner with each health system to drive change in these areas.
Patient Related Outcome Measures (PROMs)
Again, if the goal is to get the patient more involved in their care and improve communication, then Patient Related Outcome Measures or PROMs might accomplish this. CMS and the National Quality Forum (NQF) have indicated that the future of quality metrics includes PROMs. Here, the patient would indicate their health status or quality of life through a series of questions. These questions empower the patient to relate physical, mental, or social issues they may be experiencing. The data would then be aggregated over time for trending purposes and treatment options.
PROMs are early in adoption and only represent a portion of quality measurement strategies, so engagement and experience must be tackled in other ways. Yes, surveys help convey areas of change or improvement, but for ACOs, tying larger and larger percentages of shared savings to surveys from less than 1% of the ACO population seems unfair and unhelpful. How can change in the patient experience occur? Unfortunately, there is no easy answer. But it can at least start with stopping for one patient and listening.
CHESS continues to call on CMS and other payers to examine measures. Are they an accurate representation of quality and patient experience? What other mechanisms might already be in place that help give the patient experience a voice? The quality of patient care, including a patient’s experience, will always be central to value-based care, but it’s critical that it is truly what is being measured and acted upon.