Read the Full Video Transcript

Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar. I'm a urologic oncologist and health policy researcher in Nashville, Tennessee. Today, I'm really excited to be joined by Dr. David Friedlander, who is an endourologist at UNC Chapel Hill. He'll be sharing some recent work that he published in conjunction with the American Urological Association, which is a primer for healthcare performance measurement. Thanks, Dr. Friedlander, for being here today. We really appreciate it.

David Friedlander: Yeah, my pleasure. Excited to chat. Thanks again for this opportunity to discuss some important work that we've been doing at the AUA regarding the development of healthcare performance measurement and specifically how it applies to urologists. I'm going to go ahead and share what I believe are the five key takeaways from this document, and then we can go ahead and discuss them in further detail. So first off, no disclosures to report. So let's get onto the takeaways. So first and foremost, the primary objective of this document was to help explain especially to urologists, both those in the community as well as those at academic centers, the purpose of healthcare performance measurement, why we're doing it. And so ultimately, it's about trying to improve patient care as well as health outcomes. And specifically, they're meant to serve—and by them I mean performance measurements—as tools by which a variety of stakeholders can assess and enhance the quality, access, resource use, and cost associated with healthcare services and delivery.

Takeaway two is then, with that in mind, to help categorize these measurements. And so ultimately, when we think about performance measurement, we think about four broad categories, namely those that pertain to quality, access, resource use, and cost. When we then think about these categories, we can further divide them into three main types by which we assess those categories, specifically structural measurements—for example, level of subspecialty training or participation in clinical data registries such as AQUA. And these are ultimately meant to assess the conditions under which care is provided. We can also think of measures as those that are process-oriented. For example, a timely repeat of a TURBT in a T1 bladder cancer patient. And these measures assess whether or not specific healthcare-related activities that are known to lead to desired outcomes are being performed and with what frequency. And then last but not least, and probably the most intuitive measure, is an outcome measure. For example, hospital readmissions, especially when we think about that as a proxy for poor outpatient outcomes. And ultimately, these measures assess the consequences of healthcare that we deliver.

Takeaway three, in my mind, is to understand under what context or why we use these performance measures. And so ultimately, we can think of them being utilized for three primary objectives, which are improving healthcare quality, holding entities accountable—for example, accreditation or payment by a payer—and then lastly, and I think becoming increasingly important, is to make sure that consumers are making informed decisions. And by consumers, I mean patients are making informed decisions about the care that they receive. Moving on to takeaway four, I would argue it's related to understanding measurement life cycle, specifically how we go about conceptualizing the measure, specifying it—that is, defining and standardizing it to make sure that it's accurate and applicable to a broad category of individuals.

We then want to go ahead and test the measure to make sure that it's achieving its intended outcomes. And then we need to think about how to meaningfully implement it because the measure is only as good as its ability to be implemented in the real world. And then think about maintenance of that measure. Because as we know, not all things are static. If there's one thing that's consistent in healthcare, it's change. And so we need to make sure that these measures are accurately describing the outcomes, processes, or structure that we intended them to. And then ultimately, we want to think about measurement life cycle as playing a crucial role in ensuring that the measure is valid, reliable, and useful in real-world applications.

And then last but not least, the fifth takeaway in my mind is sort of the idea of advanced topics and maybe beyond the scope of this talk, but certainly an important resource, especially for those that are intimately involved in measurement development. And specifically, the document goes on to talk about how we can think about risk-adjusting these measurements. For example, in the orthopedic literature with bundled payments, there was a criticism that bundled payments, at least in their initial form, sort of unduly punished physicians that were performing surgery on high-acuity individuals or individuals with high levels of comorbidity. We also in this document talk about how to handle low case volume scenarios because, for example, when we think about large or any type of retrospective study, ultimately that study is prone to bias if case counts are low. And so how do we go ahead and handle that bias?

And then we also talk about fundamental tensions in healthcare performance measurement development. For example, using the orthopedic literature, there are inherent tensions between the individuals that are sort of on the front lines providing care and the "administrators" that may be developing these measurements. And so thinking about meaningful ways to overcome those divides and ultimately achieve the goal of performance measurement or the end goal of performance measurement, which is to improve patient outcomes and experience. So that's it. Those are sort of the five key takeaways in my mind, and I'm happy to discuss any of those in further detail with you all.

Ruchika Talwar: Great. I really love that you distilled the document into five key takeaways that we can focus on because I think the topic is really overwhelming for a lot of folks. We don't get training in performance measurements, quality improvement, things like that. So I love that now this is a resource people can reference. Let's zoom out and level set a little bit. And I think this ties into takeaway three, quite frankly, but let's just set the stage for our audience. Why is performance measurement even important or relevant in today's healthcare environment?

David Friedlander: Yeah, absolutely. So I think an example that really hopefully will resonate with individuals out in the community is just thinking about ways to make care more efficient and make the experience more—I don't want to say—but basically improve the experience for not just patients, but also for providers. So for example, if we think about these workflows, ultimately it's about standardizing care and making sure that that standardization is achieving the intended goal, not just for a small group of individuals, but for a large swath of the population.

And so if we think about someone out in the community, maybe doesn't have a lot of resources at their disposal—for example, with regards to care coordination or ensuring that individuals are receiving the recommended follow-up care—developing measures that allow you to assess how your workflow is functioning and whether or not it's achieving the outcomes that you intended is an easy way to determine whether or not there's a more efficient or higher value way to achieve care. And honestly, it can be something as simple as making sure that individuals who you intended to do annual PSA testing are in fact getting their PSA testing and that actions are being taken based upon those results.

Ruchika Talwar: I love that example. And I think you're absolutely right. It is about the patient experience, of course, but it's also about the clinician experience. There are a lot of regulatory burdens, there's a lot that comes with the documentation requirements that lead to burnout. And we know that burnout rates are rising. And so it's a great way to set the stage that performance measurements can really improve clinician quality of life while also achieving a main goal of improving care delivery for patients. So that's great. Now, that example is definitely an accurate one, but in addition to that, let's dig in a bit on how performance measurements are becoming relevant from a financial perspective. In your opinion, how have you seen this tie to physician reimbursement or potentially insurance contract rates?

David Friedlander: Absolutely. So I guess a great example of that is MIPS participation. And for those that aren't—although I suspect it's a pretty savvy audience—but in essence, physicians, practitioners including urologists, are essentially being held accountable to ensure that they are adhering to—I believe it's three out of four categories that are defined as high-value practices by CMS. So ultimately, these are examples of performance measures and, in many instances, process measures that have financial incentives tied to them. And so that's a prime example. Now granted, I do believe that MIPS is being phased out and we're moving towards value pathways, but ultimately, I think especially as specialists oftentimes think, "Oh, well, we're immune to this. Really this only applies to PCPs or folks that are participating in capitated payment models," but the reality is, I think the future of alternative payments is going to consist of some sort of global payment or capitated payment with bundled payments embedded within that global payment. And tied to those bundled payments are going to be outcome measures, process measures to make sure that we're providing high-value services.

Ruchika Talwar: That's absolutely right. And I think that a lot of urologists were participating in MIPS, and the frustrating thing is there's literature out there—the group in Michigan has published a few studies, and we've actually featured them here on UroToday—to discuss the fact that MIPS measures have nothing to do with urology, they're not accurately capturing the true quality of urology care delivered. And so I think your outline on how to capture urology-specific, clinically relevant performance measures is especially important now that MIPS is being phased out and Medicare is looking for a more accurate way to engage subspecialists in value creation. So totally agree.

The other thing to note—and your prediction, in my opinion, is spot on—is that we are no longer immune. You are right. CMS recently announced this new team model for episode-based payments for a variety of surgeries. And urology, although it's not currently included, this is just one step closer to getting to us because we are also surgical subspecialists. It's important to note that they actually included major bowel surgery, which has not been talked about quite as much as the orthopedic literature—joint replacement, cardiac surgery has been a focus—but bowel surgery is included in this mandatory model. And that tells me that urology is certainly soon to follow. So I could not agree more with all of your points, and I think that this guide is really well-timed. I'm excited to have you on UroToday to share some of your key insights. And thank you so much for your time.

David Friedlander: My pleasure. I think a closing remark I'll make is that traditionally physicians have sort of had their head in the sand as it pertains to health policy, reimbursement, but I think as we are starting to learn, that if we aren't at the table negotiating and participating in these decisions, that ultimately we're going to be subject to measures or reimbursement policies that probably are—I don't want to say ill-intentioned—but have unintended consequences that only we as frontline providers could have foreseen. So I encourage everyone to read this document and to get involved.

Ruchika Talwar: That's absolutely right. I think they are incredibly well-intentioned but have unintended consequences when subspecialists like urologists are not part of the conversation. So this really is a call to action, and I couldn't agree more with everything else you said. To our audience, thanks so much for joining us. We'll see you next time.