Transcript Slide 1

Evolving the Oncology
Medical Home
•
•
•
•
•
•
Dr. Michael Kolodziej, National Medical Director,
Oncology Solutions, Aetna
Kathy Lokay, President and CEO, Via Oncology
Barry Russo, CEO, The Center for Cancer and Blood
Disorders
Maria Sipala, Director, Strategic Planning, National
Network Contracting, Aetna
Amy Supraner, Strategic Planning Manager, National
Network Contracting, Aetna
Dr. Ira Klein, National Medical Director, Clinical
Thought Leadership, Aetna
We, too, can evolve further!
3
In the Beginning, a study: ↑ Adherence to EBM had
↓ cost with no negative impact on treatment efficacy
–
Study: “Cost Effectiveness of Evidence-Based
Purpose: Evaluate the cost effectiveness of
Treatment Guidelines for the Treatment of
Non–Small-Cell Lung Cancer in the Community Setting” (NSCLC)
evidence-based treatment pathways for NSCLC patients
–
patients according to evidence-based guidelines is a
cost-effective strategy for delivering care to those with NSCLC.
Published: Journal of Oncology Practice (American
Society of Clinical Oncology Peer Reviewed Journal), 1/19/2010
Significantly lowered cost in
the case group vs. The
control group
Conclusion: Results of this study suggest that treating
No change in overall survival
between the study groups
Source: “Cost
Effectiveness of
Evidence-Based
Treatment
Guidelines for the
Treatment of Non–
Small-Cell Lung
Cancer in the
Community
Setting”. Journal of
Oncology Practice.
January 2010.
Volume 6. No.1. p
12-18
Overall survival by Pathway
status.
4
We All Derived a Similar Equation Regarding Cost
and Efficacy in Cancer Care
Q
V=
5
C
• Guideline Based
Therapies
• Targeted Impact
• Low Toxicities
• Improved Survival
• Improved QOL
•
•
•
•
•
Best Supportive Care
Avoidance Hospital Days
Avoidance ED Visits
Site of Service Costs ↓
Medically Unnecessary
Care ↓ at EOL
Aetna Developed a Payer Strategy around this,
and so did everyone else…..but not all the same
• Drive efficient use of evidence-based medicine
– platform that provides content and workflows
– integrate into the Aetna and provider systems
– simplify the administrative processes for providers
• Avoid waste and misuse of medical services
– better provider alignment
(e.g., Oncology Patient Centered Medical Home),
– better network (narrow, tiered)
– better decision support strategies
• Leverage and integrate the many current (and future)
medical and pharmacy cancer-care initiatives
– seamless, end to end cancer experience for Aetna
members and providers
6
Who’s got Clinical Decision Support (CDS)
available in the Marketplace?
7
Where Aetna has been with “pilots” in order to
prove out theoretical concepts:
2010
2011
TX Oncology pilot
Cardinal/P4 pilot
Do Pathways tools
(clinical decision
support, or CDS) +
oncology medical
home resources
make economic
sense, contract in
commercial pop.?
Can CDS tools
alone + altered
drug fee
schedules
improve value
parameters, pay
for value contract,
all pop.?
2012
Eviti pilot
2013
TX Oncology pilot, #2
Can CDS tools alone,
without other
inducements beyond
minimal workflow
improvements, influence
NCCN guideline
compliance in all pop., no
additional economic
incentives?
Will CDS tools and
medical home
resources and tight
healthplan linkages
and reporting
improve value
parameters in
Medicare pop.,
blended contract?
8
All other cancer
care spending
elements
Payment for all other
cancer care
FFS payments
to physicians
Total Payments for
Cancer Care
Current Model
Waste and inefficiency
Payment for all other
cancer care
Care coordination fee
Case management payment
FFS payments to physicians
Total
physician
payment
Total
physician
payment
Waste and inefficiency
All other
Cancer care
Spending elements
Total Cost of Cancer
Care
The Goal is to Achieve Meaningful Payment Reform
Proposed
Model
Total physician
payment
Current Model
Proposed Model
The Brookings Institution, Washington, D.C.
All other
payments
Next Step: the Oncology Medical Home
What’s Needed for Practices to meet the Aetna
Criterion for OMH Contracting:
Oncology Medical Home Solution
Practice IT & other capabilities
Market level conditions
 Membership in Market.
 Market buy-in.
 Is there a mandatory
CDS program in state?
 Is practice in ACO/PHO?
 Must use Clinical decision
support tool.
 Perform enhanced triage,
both telephonic and in-office
 Nurse Navigator.
Practice Volume
 Infusion Suite in office
(buy and bill model) vs.
sending to outpatient
infusion center.
 40-50 Aetna Breast,
Lung, Colorectal
Cancer patients and
$500-600K per year
spend on them.
 Can conduct and collate
results of a patient
satisfaction survey.
 Can do PDCA style quality
improvement program.
11
Aetna Oncology Medical Home payment for
oncology care means growth instead of shortfall
Growth
Revenue Gap
(e.g., private payer and
CMS induced)
Current Fee
for Service
Model
Future Base
Model(s)
Without
Medical
Home-like
contracts
Invest in
Changes in
New
processes pre-cert
model alter
FTE’s
HIT Office
workflow
efficiencies
Shared
Savings on
S-codes for
improvement
quality
from
Enhanced processes
baseline
drug fee that have
outcomes
schedule meaning
Sustainable
Future
Performance
*Ultimately,
this becomes
a better
“reset”
baseline for
episodes
and/or
bundles
Our goal is to create a sustainable business model designed around new sources of
value that will be resilient through and post health care reform.
*Diagram is illustrative and for discussion purposes only
Reconciliation: Practice, Market Level Benchmarks, Financials
Practice Demographics
Market Benchmarks
Savings Calculations
Aetna Shared Savings
Practice Shared Savings
The Future: Move Providers up the Value Chain with
multiple support efforts
Vendor based
programs introduce
Clinical Pathways
and Measure
Adherence along
with Quality
Measures
Smaller
Practices
work with
Education
Oncology
programs
such as NJ
ION
program
Vendor Oncology Programs
Cardinal, New Century
Health, Innovent
More
sophisticated
Practices move
from vendor
based Clinical
Pathways
programs to
Oncology Medical
Homes (OMH)
Oncology Medical
Homes
Create episode and
bundling
methodology test
with OMH, as well as
deployed in ACO
Bundles/ Episode
Payments
OMH deployed
in 65% of
markets and
ACOs by 4Q15
OMH, ACOs,
Bundles
Provider engagement Index
Low Touch
Some Clinical
Engagement
High Touch
More Clinical
Engagement
High Clinical Engagement