Chicago, IL—People often use the terms “value” and “quality” interchangeably, but they are not the same. In the healthcare landscape, value pertains to health outcomes that matter to patients, taking into account the cost of delivering those outcomes, whereas the Institute of Medicine defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
At the Hematology/Oncology Pharmacy Association (HOPA) Practice Management Conference, held September 14-15, 2018, Emily Mackler, PharmD, BCOP, Director, Clinical Quality Initiatives, Michigan Oncology Quality Consortium, Ann Arbor, and Shannon Hough, PharmD, BCOP, Pharmacy Manager, Oncology Clinical Services, Michigan Medicine, University of Michigan, Ann Arbor, focused specifically on quality, and shared some of the quality improvement opportunities in which pharmacist participation is critical.
“As we think about how we define the quality of care we provide, it is important that we use consistent terminology so that we are all on the same page. And as we talk about how we as oncology pharmacists can impact quality, we need to make sure that how we are presenting, sharing with peers, and documenting is consistent,” said Dr Mackler.
As oncology moves toward value-based payment systems, such as advanced alternative payment models (APMs) and the Medicare Access and CHIP Reauthorization Act, pharmacists are presented with an incredible opportunity to improve the quality of care that patients receive, she explained.
The Role of the Pharmacist in the Oncology Care Model
One type of APM, the Oncology Care Model (OCM), is an episode-based, multipayer payment system developed by the Center for Medicare and Medicaid Innovation. Currently, more than 170 practices in the United States are participating in the OCM, in which practice quality is compared with that of other practices, and cost performance is compared with a practice’s own past performance.
“The OCM is becoming more and more important for a number of practices and has revolutionized the way we treat patients,” stated Dr Hough.
The OCM requires that practices provide enhanced services (ie, access to an appropriate clinician 24/7, patient navigation, a documented care plan with components from the Institute of Medicine report, patients treated in ways consistent with national guidelines), use certified electronic health__________record technology, and use data for continuous quality improvement. A number of these practice measures are shared with other quality systems, and many of them affect drug therapy and patient medication use, highlighting the importance of pharmacist participation.
According to Dr Hough, participating with the OCM has been a huge benefit to her institution, and having a pharmacist on board has been critical.
“When we are reporting data and measuring our work, we have to document in a way that is discernible and useable. Doing it is only the first step. So many of the measures for OCM, and all of these APMs, have to do with drugs. It is critical that our expertise is at the table in developing and implementing these measures,” Dr Hough explained.
For example, developing treatment plans involves determining the treatment plan and duration, expected response to treatment, treatment benefits and harms, the patient’s anticipated experience with treatment, and estimated total and out-of-pocket costs.
“These are all general concepts that can be adapted to treatment intent. But, this is all squarely in the pharmacist’s camp,” she said.
Continuous Quality Improvement
“Not only do you have to know your measures, but you have to know your performance on these measures. [With OCM], we have had to organize our data in a new way within our own registry, and we have had to be able to talk about it and implement change,” said Dr Hough.
OCM quarterly feedback reports provide practice-level data based on quarterly averages and focus on beneficiary characteristics, distribution of cancer types, expenditures per beneficiary per month, utilization, and patient experience. These reports allow practices to see how their expenditures compare with other groups in the OCM, as well as to other practices providing cancer care.
Practices can use these data to identify positive findings (eg, lower bevacizumab use compared with other practices), outstanding questions (eg, overall rates of immunotherapy compared with other centers), and opportunities for improvement (eg, multiple programmed death 1 inhibitors used for the same cancer or indication). Based on these findings, practices can then implement changes to medication use and develop clinical programs focused on areas such as collaborative drug therapy management in the ambulatory setting or prospective patient outreach.
According to Dr Mackler, pharmacists can have a primary effect on quality metrics approximately 70% of the time, and they directly affect patient counseling and education, participation in protocol-based care, managing symptoms, providing supportive care, and medication reconciliation.
“But, I also want us to think of novel ways to impact quality. Other insurers are also interested in improving quality; talk to them and think of how you can impact programs in your state,” she said.
Dr Mackler recommends engaging in quality-focused groups, such as accountable care organizations. “Much of their focus is in primary care, but they need to care about specialty too; see how you can enhance their quality of care for oncology patients.”
Additional opportunities include quality improvement–focused training, such as LEAN Healthcare Training, the American Society of Clinical Oncology Quality Training Program, the HOPA Quality Oversight Task Force, meeting involvement, scholarly work, and collaboration.
“We need to modify what we are doing. We have a great base, but it is largely terminology and vocabulary that we need to revise,” Dr Mackler concluded.