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Value Based Care Transitions:
Engaging Physicians &Patients in
Cost Effective, High Quality Cancer Care
Linda D Bosserman, MD, FACPClinical Assistant Professor
Medical Oncology & Oncology Medical HomeCity of Hope Medical Group
Patient Engagement-A New Day
� Tuesday 2-17-15 Morning Email
� PT: ‘Something New” 6:49am
� ME: Impression/Plan: 7:35am
� PT: Understanding of Plan 8:18am
� PT: Gratitude & how are labs?
9:31am
� ME: Clinic started 9:00 am
� PT: Feedback likely today
Changing Patient Engagement• The connected patient
• MU-Portals
• New devices
• New real time
connectivity & care
• Gathering PROs
• Apps
Lichter OBS 2014
What Do We Know from Patients?
Alston C et.al. IOM 2012
5
ENGAGEMENT WILL TAKE TIME &
FOCUS
EDUCATION/ADHE
RENCE
EDUCATION
REPORTING
SURVIVORSHIP
CLINICAL TRIALS
REMINDERS
DOCTOR DASHBOARD
PHYSICIAN EDUCATION
MOBILE APP
+ PATIENT
REPORTED
OUTCOMES
REAL TIME ALERTING
ACTIVATION SCORES
BEVAVIOR
REPORTING
CARE
MANAGEMENT
NAVIGATION
NURSE INTERVENTIONS
PATIENT CENTERED
CARE
ENGAGEMENT
PA
TIE
NT
SP
RO
VID
ER
S
TRACKING DATA ANALYTICS
Cook CCBS 2014
Patient Centered Cancer CareA CULTURE CHANGE: Caregiver teams Paid to Ensure
Cost Effective Patient Health & Satisfaction
*Patient Engagement :disease, health,
preferences, & satisfaction
Comprehensive, *Evidence Based Care Planning& *Coordination
Comprehensive Care Management & *Coordination
Value Based Care:Quality/Cost
and Accessibility
Engineered & EngagedPractice, *IT Supported*Coordinating All Care
Outcomes, *Quality Measure Reporting &*Ongoing
Improvement
Payer Alignment *Affordable & *AccessibleIncentivizing, Sustainable
*MEETS IOM*
High-Quality
Cancer Care GoalsOct 2013 6
Fully Engaged Patient Necessary for Best Outcomes
• Patient’s preferences important in treatment planning
• Patient/family need to actively participate in treatment
management:
– Prompting to report toxicities
– Understanding and compliance to regimen and toxicity
management
– Care coordination and navigation needs: differ by age,
resources, geography, understanding, outside support
• Patient/family need to actively participate in survivorship phase:
follow up, co-morbidities, diet, nutrition, exercise, screening &
prevention
• Patient/family need to actively engage at End of Life
Caregiver Perspective
• Balancing Many Demands
– Patient, Payer, Quality metrics, Billing/Collection,
Funding, Documentation, Value Based Care Needs,
Time Limits
» BUT
• Patient Engagement CRITICAL for Care &
Outcomes
– Engaged Patient necessary for decisions and
compliance to achieve best outcomes
• Patient defined outcomes: cost, toxicity, outcome, and
satisfaction (Family, Friends and Internet also weight in!)
• Payer wants best value: least cost for best health outcome
• TEAM needed: standardized care plans and management
Caregiver Perspective
• Balancing Many Demands
– Patient, Payer, Quality metrics, Billing/Collection, Funding,
Documentation, Value Based Care Needs, Time Limits
»BUT
• Patient Engagement CRITICAL for Care & Outcomes
– Engaged Patient necessary for decisions and compliance to
achieve best outcomes
• Patient defined outcomes: cost, toxicity, outcome, and
satisfaction (Family, Friends and Internet also weight in!)
• Payer wants best value: least cost for best health outcome
• TEAM needed: standardized care plans and management
Clinician and Practices Perspectives
Meaningful
Use1, 2,3
ICD10
Guidelines
Pathways
Plan Pilots
PQRS
Medicare
PQRS
5 Star
Medicare
IOM
Quality
Report
EMR UseCompliance
Audit ThreatsQuality Measures
Limited $$$$$
Expectations
Family/Friends
Knowledge
Clinical Trials
Data vs
Information
Media
Hype
End of LifeEnd of Life
Survivorship
HEALTH
OUTCOMES
Payment Reform For Value: Pilots 2015� Pathway Programs:Pathway Programs:Pathway Programs:Pathway Programs:
− AnthemAnthemAnthemAnthem: Cancer Care Quality Program for Medical Oncology,
2 S Codes if on pathways, 98% Cancer Pathways 2015
− MOASC, So CA; Indiana Oncology Society, IN;
− Blues/Plans: MI, PA, MD
� Oncology Medical Home Pilots:Oncology Medical Home Pilots:Oncology Medical Home Pilots:Oncology Medical Home Pilots:
− Dr. Dr. Dr. Dr. SprandioSprandioSprandioSprandio----DEDEDEDE, COME Home, Dr. McAneny, ABC Pilot Dr.
Bosserman, Innovent-US Oncology, Priority Health, MI
• 12% Cut Cancer Spend: Pathways, Diagnostics, ER/Hospital, EOL
• 2/3 of savings from reducing hospital/ER use (Dr. Sprandio data)
− Medicare: Oncology Care ModelMedicare: Oncology Care ModelMedicare: Oncology Care ModelMedicare: Oncology Care Model, Community Practices, Go live
2016, 1 S code, Pathway payment for MOH work
� United Episodes United Episodes United Episodes United Episodes of Care: 5 sites, 34% savings, 33M Net,
$40,790/patient savings
Payment Reform For Value: Pilots 2015
� California’s IPA/ACO ‘Crash courses and Thoughtful Pilots’
− So. CA Prime Care IPAs with Nearly Full Capitation for Oncology:
• Medical Home Project for Oncology Business
• Wilshire Group MOH work leads IPA to best financial performance
of 12 NAMM/Prime Care IPAs
• Bonus ONLY if group does well with overall at risk costs: drugs, ER,
hospital, ECF, RAF (risk adjusted population payments), all pooled
for bonuses, team work key among doctors, specialists
− No. CA: Hill Physician’ IPAHill Physician’ IPAHill Physician’ IPAHill Physician’ IPA: Large N. CA Group:
• Successful Oncology Successful Oncology Successful Oncology Successful Oncology Case Rate Case Rate Case Rate Case Rate Pilot
−
� Aetna: Step Wise Options: Aetna: Step Wise Options: Aetna: Step Wise Options: Aetna: Step Wise Options: to Pay for move to Value
� ASCOASCOASCOASCO: Payment Reform Work Group : Payment Reform Work Group : Payment Reform Work Group : Payment Reform Work Group Update: 3 Options, complex needs
ANTHEM Cancer Care Quality Program Our model: a Quality Initiative
Confidential & Proprietary
The Cancer Care Quality Program provides
a framework for rewarding high quality cancer care
Oncologists participating in the Cancer Care
Quality Program will receive additional
payment for treatment planning and care
coordination when they select a treatment
regimen that is on Pathway
Web-based platform with decision-support
for Quality Initiative also improves efficiency
of review against Health Plan Medical Policy
and decreases administrative burden for
practices
www.cancercarequalityprogram.com
ANTHEM: Treatment planning payments to support cost-effective care
Confidential & Proprietary
Enhanced reimbursement for treatment planning and care
coordination will be provided when patient is registered with
the Cancer Care Quality Program and treatment regimen in on
pathway
S0353 reimbursed $350 once at the onset of treatment
S0354 reimbursed $350 no more than monthly while managing
care for an established patient*
S-code billing authorization is triggered through
AIM ProviderPortal when practice selects a regimen that aligns
with WellPoint Cancer Treatment Pathways
Impact of enhanced reimbursement and support for Pathways
Mean practice revenue across regimens
S code reimbursement decreases variation in
revenue across regimens
Without S code $ 3,010 (SD $1,488) With S code $ 3,943
Confidential & Proprietary
Patient CenteredValue Based Cancer Care
Medical Oncology Home
Quality•Evidence Based
•National quality measures•Validated
•Outcome driven•Care Management
Cost•Access
•Affordability•Cost Effective Pathways•Interval Care Mgmt: •Less ER and Hospital
•EOL Care•Diagnostics
Payer Partnership•Value based payments•Partner with delivery
system•Partner with patient
•Sustainable
Delivery System•Care givers/Caring
•Research•Facilities 24/7 Access
•Pharmaceuticals•Devices
•IT Facilitated•Networked with Providers
16
MOH Population Care Details for PPO and HMO Patients
Plan Type
Patient Categories
ABC PPO
24 Months
Prime Care IV
Total
24 Months
Prime Care IV
Commercial <65
Prime Care IV
Seniors >65
Population
Numbers
Unknown
for PPO
39,451 (Average 24 months)
32,082 7,369 (7000 up to 8000)
Patients Seen 723 1139 395 744
New 146 252 98 154
On Therapy 243 (34%) 280 (25%) 104 (26%) 176(24%)
Chemo-Bio 137 (19%) 182 (16%) 65 (16%) 117 (16%)
Hormone Only 106 (15%) 98 ( 9%) 39 (10%) 59 ( 8%)
Pall/Hospice 10 19 4 15
Died 17(2%) 40 (3.5%) 7 (2%) 33(4%)
On Follow Up 480 859 296 563
17
24 Month
ABC PPO Pts
Care Cost
Details
Care Cost Savings Care Planning Care
Management
Cost: Practice,
IT, MOH care
On Therapy Chemo-Bio -IV: $313,000-Orals: Pending
151 plans 1209 cycles
Hormone -Oral: Pending
Bone Mets $245,000
WBC GF $505,000 <5% to >64% 22% 30/137 1pt St IV WBC GF
Interval Care ER Avoided 3% less 26% ABC 32/137, 23%, (1/3 non cancer)
Hospital 8% less19% less avoidables
30% ABC
26% avoidables
22% InPt 30/137
7% avoidables
10/137
32/137,23%outP
(Half non cancer)
End of Life Rx to death 9.5 weeks
Hospital 30d 20% less 55% ABC 35%, 6/17 Pilot LOS 10:2,2,7,7,8,34
ICU last 30 d 34% less 44% ABC 6% Pilot 1/17
Deaths: Home
vs. Hospital
32% MORE
Hospice/Pal use 27% ABC
65% Pilot 11/17
10/17 Pal/Hosp
Died at home
=59%
Total Savings Benchmarks ABC vs Others
Total Costs ? OnRx + Others $75,500 CP Rx + $725,400 CM Rx+ Calculable
Total Pay Medicare/ABC/ Pilot Estimable Calculable
Oncology Case Rate (OCR)Payment Reform Example
Larry Strieff, MD, Specialty Medical Director, Hematology Oncology Division Chief
Clinical Support, Hill Physicians Medical Group
Hill Physicians Medical Group�Independent Physician Association founded in 1984
�Provider network: 3,800 providers and consultants� 980 Primary Care
� 2,260 Specialists (170 Oncologists)
�Service the Northern California area� 300,000 Members
� 5 Regions - 9 Counties
20
Larry Strieff, MD, CCBS 2014
Methodologies Evaluated21
Mutually
SustainableFFS
FFS & FFS &
Cap
Flat Cap
Rate
Drop to
MC Rates
Drop to
MC Rates Aligned Incentives*Cost
*Quality
*Patient Experience
Cohort
Case Rate
Larry Strieff, MD, CCBS 2014
Chronological Cost Pattern for Breast Cancer
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35
Pai
d p
er
Cas
e
Months Following Initial Diagnosis
Other Radiology
Radiation Oncology
Medical Oncology
22
Larry Strieff, MD, CCBS 2014
Oncology Case Rate (OCR)Bundled Payment System
23
Episode of Care Reimbursement
Cancer Cohorts by Diagnosis
Budget Set Aside for Stop Loss
Removal of Prior Authorization
Quality Management Program
Monthly episodic payment for all oncology-related
services
Cost variation across different cancer types
Ensure fair allocation of risk
Reduce barriers to enable evidence-based cost-
effective care
1. ASCO QOPI Measures
2. Utilization Measures
3. Satisfaction Measures
Larry Strieff, MD, CCBS 2014
OCR Cancer Cohorts:Diagnosis Group by Cancer Type
24
Cohort Cancer TypeTotal Unique
Patients, 2010-2014 YTD
1 Colon & Rectum 116
2 Lung 136
3 Breast (female) 287
4 Ovary and other Uterine Adnexa 23
5 Prostate 41
6 Malignant Neoplasm of Other/Unspecified Sites 50
7 Malignant Neoplasm of Lymp/Hema Tissue 169
8 Other Malignant Neoplasm 158
9 Diseases of Blood & Blood-Forming Origin 27
Total Unique Patients 1,007
Larry Strieff, MD, CCBS 2014
Trends in Oncology PMPM25
Larry Strieff, MD, CCBS 2014
Quality Management Bonus Program�Program encompasses 3 domains
�Clinical measures are subject to audit and chart reviews
�Performance dashboards are shared with oncology groups regularly
26
Clinical Quality Domain
• ~30 QOPI ASCO Clinical Measures
• Subject to Hill review/audit
Satisfaction Domain
• Referring Provider Satisfaction Surveys
• Patient Satisfaction Surveys
Utilization Domain
• Inpatient Bed Days
• Infusion Center Use
• Chemotherapy Initiation
• ED Visits (2014)
Larry Strieff, MD, CCBS 2014
Clinical Quality of Care
27
83.0% 82.0%
87.1%
95.9%
60%
70%
80%
90%
100%
2010 2011 2012 2013
ASCO C
linical Q
uality
Perform
ance (30 Q
OPI M
easu
res)
OCR Performance
ASCO = American Society of Clinical Oncology
Larry Strieff, MD, CCBS 2014
28
Larry Strieff, MD, CCBS 2014
3,177
2,724
2,982
2,889
2,400
2,600
2,800
3,000
3,200
3,400
2012 2013
# I
np
ati
en
t B
ed
Da
ys/
10
00
Me
mb
ers
OCR Non-OCR
OCR Group saved > $1 million
from decreasing bed days
Larry Strieff, MD, CCBS 2014
Utilization Measure
29
Inpatient Bed Days
Overall Survival Results30
OCR (N=128) vs. Control (N=146)p = 0.05
All 4 Cancer Cohorts (N=274){Esophageal, Pancreas, Lung, Stomach}
Survival Time (days)Day 0 = first day of chemotherapy
Survival Probability
Larry Strieff, MD, CCBS 2014
Summary� OCR practices demonstrated year-over-year improvements in performance on ASCO clinical quality measures.
� OCR practices out-performed standard FFS model in satisfaction and utilization metrics year-over-year.
� OCR practices’ overall survival is non-inferior to the overall survival under a standard FFS model.
� Significant cost savings of greater than $7.5 million in 3.5 years of program experience.
31
Larry Strieff, MD, CCBS 2014
Oncology reimbursement reform
is a step-wise process
Vendor Oncology Programs Oncology Medical Homes
Bundles/ Episode Payments
OMH, ACOs, Bundles
Vendor based programs introduce Clinical Pathways
and Measure Adherence along with Quality Measures
More sophisticated
Practices move from vendor based Clinical Pathways programs to Oncology Medical Homes (OMH)
Smaller Practices work with Education Oncology programs such as NJ ION program
Create episode and
bundling methodology test with OMH, as well as deployed in ACO
Provider engagement Index
Low Touch High Touch
Some Clinical
Engagement
OMH deployed in 65% of markets and ACOs by 4Q15
More Clinical
Engagement
High Clinical Engagement
Kolodziej, CCBS 2014
ASCO’s Work to
Improve Payment
for Oncology Practices
CPC Board Update, Dr. Harold Miller 2-15
ASCO’s Efforts to Lower Costs, Increase Value
� Promoting Adherence to Evidence-Based Medicine: ASCO
Guidelines
� Participating in & Promoting “Choosing Wisely”
� Commitment to Quality Improvement: QOPI
� Working with Payers: Integration of Quality Measures into
Reimbursement Decision-Making
� Cultivating a Learning Healthcare System: CancerLinQ
� Establishing Clinically Meaningful Outcomes in Cancer Research
� Payment Reform
� The Value in Cancer Care Task Force
35© 2013-2015 American Society of Clinical Oncology, Center for Healthcare Quality and Payment Reform
DEFICIT
There is Currently No Way to Pay
for Improved Care for Patients
MD/DOSalaries
NursingSalaries
Other Staff Pay
PharmacyOp. Costs
Rent,Utilities,Equip.
E&MCodePmts
InfusionCodePmts
DrugMargin
NOTE: Chart not drawn to scale
$
MD/DOSalaries
NursingSalaries
Other Staff Pay
PharmacyOp. Costs
Rent,Utilities,Equip.
E&MCodePmts
InfusionCodePmts MD/DO
Salaries
NursingSalaries
Other Staff Pay
PharmacyOp. Costs
Rent,Utilities,Equip.
E&MCodePmts
InfusionCodePmts
MD/DOSalaries
NursingSalaries
Other Staff Pay
PharmacyOp. Costs
Rent,Utilities,Equip.
E&MCodePmts
InfusionCodePmts
DrugMargin
DEFICIT
DEFICIT
DrugMargin
DrugMargin
MedicalHomeCosts
DEFICIT
COSTS REVENUE COSTS REVENUE COSTS REVENUE COSTS REVENUE
CURRENTSHIFT TO
GENERIC DRUGSSHIFT TO
ORAL DRUGSIMPROVEDCARE MGT
36© 2013-2015 American Society of Clinical Oncology, Center for Healthcare Quality and Payment Reform
Current Payments Underpay all Care Phases:New Patient, Infusion, Oral and Survivorship
NOTE: Chart not drawn to scale
$
Timeand
Costs
E&MPmts
COSTS REVENUE
NEW PATIENTTREATMENT MONTH
(INFUSION)TREATMENT MONTH
(ORAL)NON-TREATMENT
MONTH
E&MPmts
COSTS REVENUE
Timeand
Costs
E&MPmts
COSTS REVENUE
Timeand
Costs E&MPmts
COSTS REVENUE
InfusionCodePmts
DrugMargin
Timeand
Costs
37© 2013-2015 American Society of Clinical Oncology, Center for Healthcare Quality and Payment Reform
New Billing Codes
• New Patient Treatment Planning: This would be a one-time payment for each new patient to cover currently unfunded and underfunded costs related to diagnosis, treatment planning, and patient support prior to the beginning of treatment.
• Monthly Care Coordination and Management: This would be a monthly payment for each patient during the period of time in which treatment is underway and for six months after treatment ends, in order to cover currently unfunded and underfunded costs of patient education, care coordination, and rapid intervention to address complications of treatment.
• Monthly Oral Anti-Cancer Therapy Management: This would be a monthly payment for each patient during months in which they are receiving oral anti-cancer therapy.
38© 2013-2015 American Society of Clinical Oncology, Center for Healthcare Quality and Payment Reform
Transitioning from Payer-Defined
Rules to ASCO-Defined Rules
Payer-Specific Prior
AuthorizationRequirements
Payer-Specific Prior
AuthorizationRequirements
Payer-SpecificProprietary
Pathway
Payer-SpecificProprietary
Pathway
TODAY
ASCOChoosing
WiselyGuidelinesand QOPI
End of Lifeand
Overuse Measures
ASCO-Developed
or EndorsedPathways
PAYMENT PILOTS FUTURE
An Employer’s View on Cancer Costs
39
Employees with cancer result in more than 33 million
disability days per year.1
Of the 12 million Americans with cancer today, an
estimated 3 million are actively employed.2
Since employer’s cancer medical expenses are increasing faster than general
medical costs, there is no waiting for payment reform – employers are
increasingly taking direct action to manage cancer costs now
Sources:
1. “Cancer Costs Billions Yearly in U.S.” US News and World Report. December 2012.
2. Miller, S. “Employers Focus on Cancer Prevention and Care.” Society for Human Resource Management. November 2013
3. Herr, J. “Employers Becoming More Savvy About Specialty Pharmacy, but Need More Cost Controls.” Midwest Business Group on Health. February 2013.
Specialty oncology drugs currently account for approximately 17%
of the average employer’s total pharmacy spend and are
estimated to rise to 40% by 2020.3
Denise K. Pierce CCBS 2014
Employer Approaches to Managing Cancer Costs
Employer Initiatives
There is a wide variation in approaches, based on company industry, size, and
employee demographics
Claims data warehousing/analysis
Specialty pharmacy benefit
Nurse navigators
Value-based payment design
Oncology medical homes
Solid tumor mapping
• Overall cancer costs/targeting
• “per employee” costs for benefit forecasting
• Case managing the “right treatment for the right patient”
• Integrating adherence measures
• Care coordination beyond the practice doors
• Drug/treatment adherence
• Oncology pathway integration
• Natural narrower networks based on participation
• Learning from current primary care models
• Individualized treatment decision support
Source: DK Pierce & Associates, Inc. DKP Critical Insights®: Employer Cancer Management Evolution Analysis 2014.
Denise K. Pierce CCBS 2014
Oncology Reimbursement Reform MUST:
�BOTH: Reduce costs AND Improve quality
�Develop Sustainable Business models
�Integrate Multimodality Costs: (TCPI Grants)
−Surgical Oncology, Radiation Oncology,
Rehabilitation Services, Transplant, Trials
−Primary Care Coordination
−Better Patient Engagement
�IMPROVE OVERALL HEALTH OUTCOMES
Kolodziej, CCBS 2014
Four Revolutions in Oncology
Cancer
Panomics Big data
Payment
reform/ValuePatient
engagement
Lichter OBS 2014
ASCO Responds: Cancer LINQ: Learning Intelligence Network for Quality
Lichter OBS 2014
#4 Pan Omics• Diagnostic Testing
– Molecular analytics at diagnosis
• Treatment pairing
• Prognosis
• Prevention
– Molecular analysis of metastasis/recurrences
• Treatment stratifications
• Clinical Trial specifity
• Genomics, Proteomics, Metabolomics
• Challenge of Test, Interpretation, Meaning
Value Based Care Transition• Re-Engineering of
– Clinician Roles, Processes, IT and Data collection
• Team based care, continuous support for patients
• Minimize ER, Hospital and futile therapies
• Maximize trials and targeted care with high value
• IT facilitated data collection and analytics support rapid
improvements in larger systems of care
– Patient engaged, educated regarding values and
preferences with more informative tools
– Payer relationships: support value based care
• Cost + margin based on outcomes and quality measures