Transcript Quality and Value: A Medical Oncology Home In your

New Payment Systems in Oncology:
Aligning Incentives for
Value and Accountability
Linda D Bosserman, MD, FACP
Medical Oncologist and President
Wilshire Oncology Medical Group
Affiliated with US Oncology
Disclosures
• President and stockholder of Wilshire Oncology
Medical Group
• Consultant for US Oncology
• Received grant/research support from Pfizer
Pay Differently for Different Outcomes:
Aligning Information and Incentives
 Current System Pays for Volume and Drugs and has inadequate data for
meaningful evaluations of care, quality, costs or value
 New Payment Systems Need to Align Goals:
 Patients need:
 Ability to evaluate quality and cost of care by different groups
 Access to high comprehensive care, clinical research and support services
 Practices with approaches that achieve high patient satisfaction
 Lowest costs for best outcomes and choices on how to spend their money
 Payers need:
 Lowest Costs for Highest Quality of Care in most appropriate Site
 Targeted reports on delivered care, outcomes and costs
 Lower administrative burden for auth and UR, lower MLR
 Payers needs to work closely with Provider Delivery Network
 BUT: Payers need new systems and relationships to meet these needs
Pay Differently for Different Outcomes:
Aligning Information and Incentives
 New Payment Systems Need to Align Goals:
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Oncology Delivery Networks Need:
 Support tools and engagement by providers
 Evidence based care prompting at the bedside with warranted
variations
 Clinician leadership for high quality care coordination and
documentation for analysis & reporting
 Comprehensive approaches to lower costs of doing business:
supplies, HR management, benefits, networking, contracting,
data analysis and business management
 UR, UM and Authorization functions within the care delivery
model
 New Payment Systems Need to Align Goals:
 Clinicians need to Lead the Care Delivery Model
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Development & Implementation of Evidence based
Guidelines and warranted variations (tools and techniques)
Coordinate all aspects of cancer-related evaluations and care
Lead the delivery team: Mid Levels, RN, MA, Admin Staff
Oversee/Coordinate the sites of care: office, urgent care, ER,
Hospital, Hospice, Home Care
Supported by oncology delivery networks to leverage expertise
and cost savings benefits
Hematology & Oncology Challenges
 Significant growth in cancer incidence expected in next 5 and
10 years
 CARE COORDINATION NEEDED for complex cancer
patients throughout the continuum:
 Primary care, specialists, infusion, after hours, disability,
rehabilitation, urgent care, ER, Hospital, tertiary care, clinical
trials, psychosocial support, palliative care & hospice,
 Prevention, Screening, Diagnosis, Therapy, Support, Recovery ,
Survival Plans, Palliative Care and Hospice
 Data Needed to analyze quality, value and care needs
 Partnership between Payers and Oncology leadership
 Partnership between patients, payers and providers
 New Contracting needed to align incentives
 Cancer Care Management to achieve quality and value
Findings from Milliman Report 1*
 Cancer patients are less than 1% of a commercially insured
population, but they account for over 10% of costs
 The variation in medical utilization and costs for cancer patients
highlights an opportunity for better management
 In particular, cancer patients receiving chemotherapy have high
costs averaging $111,000 annually, approximately 4x the cost of
cancer patients not receiving chemo
 Opportunities for quality and cost improvement for cancer
patients on chemo include:
 Reduction in chemo costs
 Reduction in chemo sensitive admissions
 Reduction in ER sensitive admissions
*Commissioned by US Oncology 10/09; Source:Milliman Analysis of Medstat 2007, 14 million commercially insured lives
Cancer Costs Are Rising Beyond Inflation, Other
Healthcare Costs
$55 B
Cumulative % Increase
Cancer Drugs
$123 B
US GDP1
Healthcare2
Cancer Medical
US GDP
2009
$15.5 T
9.2%
$2.5 T
Cancer Medical3 15.0%
$93.0 B
15.1%
$42.0 B
Cancer Drugs4
Healthcare
Annual
Increase
-2.4%
Sources
1 Bureau of Labor and Statistics
2 Kaiser Family Foundation, CMS National
Health Expenditures data
3 American Cancer Society, US Oncology data
4 Medco Health Solutions 2009 Drug Trend Report
Oncology Drugs are leading the Drug
Development Horizon
 400 new oncology drugs in pre-clinical or clinical development
 171 in late stage trials
 Market projected to double from $26 B in 2004 to $55 B in 2010
Drugs in Clinical Trials
Oncology & Hematology
171
Central Nervous System
167
Cardiovascular
136
Respiratory
91
Infectious Disease
91
Cancer Incidence Concentrations Vary Significantly:
IE: Eastern LA-San Bernardino, & Riverside Counties
 The 2008 adjusted cancer incidences within defined area is 11,991
 The compound annual growth rate of cancer incidence is 2%
2008 Adjusted Cancer
Incidences by Zip Code:
250
125
0
Wilshire Oncology
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Cancer Incidence by Cancer Type
in Eastern LA, San Bernardino and Riverside Counties
Breast, prostate, lung & colorectal cancer incidences represent 54% of all cancer
incidences in the Inland Empire region
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Cancer Type
BREAST
PROSTATE
OTHER
LUNG
COLORECTAL
NH LYMPHOMA
MELANOMA
BLADDER
UTERINE
LEUKEMIA
THYROID
ORAL CAVITY
KIDNEY
PANCREAS
STOMACH
OVARIAN
BRAIN
CERVICAL
Totals
2008 Incidence
2,809
2,153
1,900
1,826
1,709
684
582
561
451
446
405
392
392
391
339
285
226
193
% of 2008
Incidence Total
18%
14%
12%
12%
11%
4%
4%
4%
3%
3%
3%
2%
2%
2%
2%
2%
1%
1%
2013 Incidence
3,116
2,452
2,133
2,072
1,943
762
620
630
503
492
439
443
440
446
396
316
245
211
% of 2013
Incidence Total
18%
14%
12%
12%
11%
4%
4%
4%
3%
3%
2%
3%
2%
3%
2%
2%
1%
1%
CAGR
2.1%
2.6%
2.3%
2.6%
2.6%
2.2%
1.3%
2.4%
2.2%
2.0%
1.6%
2.5%
2.3%
2.7%
3.1%
2.1%
1.6%
1.8%
15,742
100%
17,657
100%
2.3%
The “Other” cancer category includes all cancer specific ICD-9 codes (140-208 & 230-239), however, is not included within the
above cancer definitions, as the majority of these “other” cancers are identified as malignant neoplasms of uncertain behavior
whose point of origin could not be determined.
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Data to Understand Population
 What is your Hematology-Oncology population?
 Prevention and Genetic Risk:
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Assess and return to primary with care plan
 Screening Programs coordinated with primary care
 New abnormalities with possible cancer
 Initial diagnostic work up with primary and specialists,
oversight of tertiary care referrals and care coordination
 Patients with Cancer or blood diseases
 Early/Curable Patients
 Advanced or Recurrent Cancer Patients
 Patients on follow up
 Palliative or Hospice Patients
Data for Therapy Population-1
 Patient Info
 Disease, Stage, TNM, Tumor Features, Dx Date
 Treatment Plan: medical, surgical, XRT, other
 Performance Status and co-morbidities
 Therapy Regimens
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Name, # cycles, Goal, Start/Stop, Guideline compliant, Cost
vs. Alternative, Reason for any variances
Type and Line of Therapy with goal (cure/palliation)
 Support Regimens: Nausea and Growth factor
 Regimen, #cycles, guideline compliant, cost vs. alternative
Data for Therapy Population-2
 Adjuvant/Neoadjuvant Therapies
 Guideline adherence vis a via tumor features
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ER/PR/Her2 for Breast, OncoDx or MammaPrint risks
Adenocarcinoma vs. squamous cell for lung
K-ras for Colorectal
 Metastatic or Recurrence Therapies
 Cost of regimens
 Response to regimen
 Duration of response to regimen
 Performance status
 Hospice discussion documented for 2nd line and beyond
 Hospice and Palliative care costs and benefit analyses
Data Can Help Us Improve Care
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Which Patients with which characteristics benefit?
How do performance status and co-morbidities factor in?
How do we coordinate cost effective prevention strategies?
What is cost effective for diagnostic and follow up studies?
What are the cost effective evidence-based therapies?
What are the cost effective support medication regimens?
How are clinical trials integrated and at what cost/benefit?
How do we coordinate care cost effectively?
 Med Onc, Rad Onc, Surgery, Reconstruction, Rehabilitation,
Support
What can be done in office and extended urgent care vs ER and
hospital care?
How are palliative care and hospice introduced and used?
Tracking Total Cost of Care
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Track Total Cost of Care for Patients
 Cost effective prevention and diagnostics
 Cost effective therapy and support with care coordination
 Cost effective site of care management
 Cost effective end of life care management
Coordinate and manage out migration to tertiary care
Clinical Trials: Integrate in network, track trial patients
 Regimen standard vs. investigational care given
 Track savings from free investigational drugs vs. standard
 Track any ‘extra’ care on trial and ensure billed to trial
If metastatic disease
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Track therapy, PS, lines of therapy and outcomes
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Discussion of palliative and hospice care,
Track time off Therapy and time on Hospice
Track time off therapy to death
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Oncology Medical Home Pilot
 Comprehensive Reporting on Accountable Care
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Demographics, diagnoses, co morbidities, performance status
Initial Consult, Prevention, Recurrence, Follow up, Transition
back to primary and Hospice-Palliative care
Therapy: Cost Effective therapies and supportive care
Clinical trials integration
Care management: symptoms and side effects
Care Coordination: surgery, XRT, tertiary care, others
Site Optimization: ER/hospital vs. clinic/urgent care
End of Life Care
ASCO QOPI quality measures
Oncology Medical Home Pilot
 Pay differently for Different Outcomes
 Partnership with payers to understand issues of patients, providers
and payers: many challenges
 Identify key issues, validation needs and costs for both sides
 Develop incentives to align goals
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Tiered drug pricing/supports greater Pathways adherence
 Pilot: Pay for desired services
 E&M, Therapy, Drugs: oral and IV
 Care Planning and Care Management Code Payments
 Management: UM, UR, Authorization and Reporting
 Track: projected savings from cost effective, coordinated care
driven by payment for comprehensive planning and care
management
Oncology Payment Pilots
 United Health Care
 5 Sites, bundled payments for Breast, Colon and Lung
 Evidence based pathways, tracking of care costs/savings
 Aetna -USON Innovent
 Via Health: U Pittsburg Pathways
 P4 Health: drug payment differentials
 ABC-Wilshire Oncology
 Comprehensive care delivery and cost reporting
 Pathways, Care Management, End of Life care
 Standard payments + Care Management & Care Planning
Health Plan & IPA Support
 Community Oncology Networks Can:
 Bring practitioners together for common care pathways
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Provide evidence based pathways – monitor & measure
 Support practitioners
 Regional tumor boards and expert consultations
 Program and update Oncology EMR for Care Pathways
 Standardize IPA and health plan reporting and care tracking
 Regionalize urgent care, hospital and tertiary care referrals
 Share Clinical trials at regional sites to avoid outmigration
 Standardize cost effective care and support regimens
 Standard clinic processes: education, consent, delivery, reporting
 Lower supply costs by enlarging the specialized network
 Support Medical Directors and Administrators
 Financial and Care Delivery reporting for contracting support
 Utilization management tools
Questions & Discussion