Transcript Renal Pathways Committee - Washington State Medical

Why Pathways? Why Now?
“Payers”
Cancer
Landscape
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Patients
Fully vs. Self Insured Health Plans
Employers / Brokers
Medicare / Medicaid
ACO’s???
10% of $pmpm Spend
Managers/Tools
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Compendia
Formularies
Prior Auth / UM
Specialty Pharmacy
Infusion Centers
Drug Fee Schedules
Guidelines
Pathways
“Suppliers”
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Pharma/Biotech
Imaging Vendors
Rad Tech Vendors
Spec Lab Vendors
Providers
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Surgeons
Med Onc’s
Rad Onc’s
Hybrids
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Clinically Integrated Networks
Hospital Owned / Affiliated
Practices
Multi Disciplinary Practices
Practice Management Co’s
Academic Centers
Why Pathways? Why Now?
Pathways are a proven model for tangibly demonstrating VALUE (Q/C)
to your key stakeholders (patients, referring MD’s, hospitals, payers)
in the new healthcare milieu
And retaining control over decision making for your patients…
Agenda
• Brief history of “Why Pathways at UPMC”
• What do we mean by Via Oncology Pathways?
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How are Pathways developed & maintained?
What diseases / modalities / phases of care are addressed?
How are the Pathways “delivered” and measured?
What are the implementation options?
What is the road map for Pathways for 2012?
Who is using the Via Oncology Pathways today vs. tomorrow?
• Can we prove success?
• How can the value of Pathways be monetized?
• Demonstration of the Pathways Portal
2004 - 2009
2009 - 2011
January
2011
Providers
UPMC
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UPMC is a large not-for-profit health system providing both leading health
services and insurance in Western Pennsylvania and the surrounding area.
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UPMC is the region’s largest employer, with 50,000 employees
(including 2,800 physicians), 20 tertiary, specialty, and community hospitals,
400 outpatient sites and doctors’ offices, and retirement and long-term
care facilities as well as international ventures
UPMC Stats
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Revenue:
7 Billion
Assets:
6-7 Billion
UPMC Cancer Centers
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UPMC Cancer Centers is an distinct product line of
the UPMC system
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Organized via a “regional hub and satellite” structure
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Inpatient and specialized treatment provided at
central “hub” while outpatient care is offered at
over 40 regional sites
Academic and Community Based physicians treating
30,000 new patients per year
Needs at UPMC
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2000 - 2004
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Rapid expansion of the “UPMC Cancer Centers” brand to 25 sites of
Medical Oncology service with a 250 mile geographic spread
Concerns over Quality and Consistency of Care
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Internal study revealed significant variability, though mostly within Guidelines
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Some care outside of Guidelines
Payers demanding solutions to the rising cancer costs
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Take charge or lose control…
Our Solution: Via Oncology Pathways
• Continually updated, evidence-based treatment algorithms
for most cancer presentations and unique patient comorbidities,
• Developed and maintained by the oncologists themselves,
• Delivered in a point of care, patient specific, interactive
decision support tool,
• Resulting in measurable proof of performance and likely
savings in healthcare resources
Via Oncology Pathways vs. Guidelines
Via Oncology
Pathways
Variability Allowed
Guidelines
Guidelines
Cancer Incidences Covered
Via Oncology
Pathways
How are Via Oncology Pathways developed
and maintained?
• Physician Disease Specific Committees (18 unique committees)
– Two co-chairs for each committee (academic & community based)
– Committee participation open to all Via Oncology Pathways physicians
• Committee Process:
– Conflict of Interest Disclosure
– Review prior period metrics by patient presentation
– Where physicians are going Off Pathway >30%, review reasons cited and what regimen
was used instead
• Consider adding additional “sub-presentations” to achieve goal of 80% coverage
– Review new evidence and debate until consensus is established for a single-best
What is “single best”?
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Disease Committees define a single best treatment for each state and
stage of disease based upon:
First Decision Tier:
Efficacy
- If there is a clear choice,
this is the pathway
Second Decision Tier:
Toxicity
- If efficacy is
comparable…pick the
treatment with less toxicities
to improve QOL and reduce
hospitalizations/ED visits
Third Decision Tier:
Cost
- Only if efficacy and
toxicities are
comparable…pick the
lowest cost treatment
“On Pathway” Rate Goal:
70-90%
How often is Pathway maintenance
performed?
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Quarterly meetings to review new data and change
Pathway if needed
Software is updated (after MD review) for ALL
customers within 2-4 weeks of approved Pathway
change by committee
For “game changing” new data, call Ad Hoc
committee meeting
Medical Oncology Disease Coverage
Breast
Prostate
Lymphomas
Myeloma
Head & Neck
Melanoma
Colon/Rectal
Lung
MDS
Ovarian
Esophageal
Renal
Bladder
Gastric
Pancreatic
Uterine
CML
95% of all new cancer cases
Modality Coverage
Medical Oncology Treatment
Radiation Oncology
Treatment
Infused Chemo & Biologics
Conventional 3D
(Avastin, Erbitux, etc)
IMRT
Orals
SRS
(Xeloda, Tykerb, etc.)
Brachytherapy
Supportive Care
Antiemetics
(5HT3’s, Aloxi, Emend)
WBC Growth Factors
Prognostic Testing
(Personalized Medicine)
Her2
KRAS
OncotypeDX
EGFR
Advance Care Planning
Prompts physician to consider
hospice/palliative care for METS
Document Treatment Intent and how it
was discussed with patient
Prompt Physician to consider hospice
upon each disease progression
How do we make it easy for
the physician to use the
pathways?
And prove their results???
11/10/2010 –
Peter G. Ellis,
M.D.
The Pathways Portal
Novel Software Application
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Point of Care Decision Support Tool
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Patient Specific / Personalized
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Interfaced with practice’s
demographics and scheduling
applications
Easily Implemented
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Physicians utilize when selecting
treatment
Web-Based Application (centrally or
locally hosted)
Stand Alone or Integrated with EMR
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Avoids duplicate entry of treatment
orders by physicians
The Pathways Portal
Focused on Physician Efficiency
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Highly intuitive and user friendly
• Minimal training required
• Presents the “right patient at the right
time”
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Provides additional tools to Physician
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Chemo Order Sets (for non EMR sites)
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Clinical references and full text articles
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Patient Education Materials
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Dose Modification Guidelines
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Staging references
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Email alerts to physicians each day
regarding prior Missed Patients
Supporting Clinical Research
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Practice specific trials imbedded in
Pathways Portal
Trials are always 1st option in
Pathways
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Trials are always counted as “On
Pathway”
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If patient NOT accrued, require
“Reasons for Not Accruing” are
captured and reported back to PI’s
Implementation Options
Physician
Decision Support
Tool
OR
Staff Data Entry
Tool
Standalone
Application
OR
Interfaced to
EMR
Diseases:
Some or All
Pathways
Treatment
Regimens:
Via Oncology
Standard or Practice
Customized
Patients:
All or Payer
Specific
Peer Review:
On or Off
Clinical Trials:
All, Some, or
none
Why can’t you get Pathways in an
EHR*?
EHR
Functions
* - with the possible exception of iKnowMed
2012: Laying down additional lanes!!!
• Deeper integration with Aria EMR
– Inbound clinical data such as Stage, Her2, etc.
– Outbound orders
• Expand pathways for:
– G-CSF’s
– Prognostic Testing – what should/should NOT be ordered
– Surveillance / Survivorship Pathways
• Phase II of Advance Care Planning
• “Virtual Tumor Board” within Portal
Market Expansion
RESULTS:
Adherence
&
Cost Savings
Pathways Metrics
9 months ended Sept 30, 2011:
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94% Patient Capture Rate (denominator is all patient visits – 280,000
visits per year)
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77% “On Pathway” Rate (denominator is all new treatment decisions
– 17,000 annual new treatment decisions)
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Goal is never 100%...intended to meet the majority of clinical situations
but never all… 80-90% is general goal.
100% capture of Reasons for Going “Off Pathway”
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Most common (30%) is Exceeded Line of Therapy
Types of Cost Savings Studies
Breast
&
NSCLC
Total Cost of Care
Total Cost of Care
Patients seen at
Pathways Practice
vs.
Practice Based Services
NSCLC Only
The 80% of Patients “On”
Pathway
Patients seen at
NON-Pathways
Practice
Practice Based Services
vs.
The 20% of Patients
“Off” Pathways
Via Oncology
Studies
with Highmark
BCBS
US Oncology
Study with Aetna
35% difference in
outpatient costs
Journal of
Oncology Practice
January 2010
Highmark Study Design
Two Separate Studies:
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Breast and NSCLC
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Population Studied
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Analysis completed by Highmark using Highmark claims data
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Patients in active therapy (excluded patients in remission)
• Both commercial and Medicare Advantage with full coverage (e.g., Rx Benefit
with Highmark)
Measured Total Cost of Care, not just drugs
Two arms
• Control = non-UPMC patients (40%)
• Experimental = UPMC patients (60%)
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Two periods measured
• 12 months before Pathway implementation
• 12 months after Pathway implementation (measured months 6-18 to give a 6 mo
gap for ramp up)
Highmark Cost Savings – Total Cost of Care
• Highmark/UPMC - Breast Study Results (see details in Appendix)
– 9% absolute Growth Rate differential
• 16% growth in Non–Pathways Practices
• 7% growth in the Experimental Arm – Pathways Practices
• Highmark/UPMC - NSCLC Study Results (see details in Appendix)
– 5% absolute Growth Rate differential
• 6% growth in Non–Pathways Practices
• 1% growth in the Experimental Arm – Pathways Practices
Cost Savings Study – Drugs Only
IntrinsiQ Study of NSCLC Drug Costs
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Large oncology EMR and data analytics company
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Database of EMR prescribing data for 700 nationally distributed oncologists at very granular
level
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Compared for Non Small Cell Lung Cancer:
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Regimen
Disease and Stage
Line of Therapy
Performance Status
Clinical Markers (Her2, etc.)
Real world treatment patterns versus
UPMC / Via Oncology Pathways
Results:
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10% savings on Drug Costs if adhered to national Guidelines
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40% savings on Drug Costs if adhered to Via Pathways
• Assuming an On Pathway Rate of 80%, the savings would likely be 32%
Up Next – Look for results from Horizon Study
• Two community based practices in New Jersey
• Similar study design to Highmark except no radiation costs
• Results compiled this month by 3rd party hired by Horizon
• Shows costs grew in Non-Pathways practices compared to substantial
reductions in Pathways practices
• Working towards publication in early 2012
How do you monetize the
VALUE of Pathways?
Internal Practice Value of Pathways
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Lower bad debt risk
• Staying “on” Pathway reduces risk of Payer denials
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Practice efficiencies through uniformity of care and less variability
• Staffing productivity
• Lower inventory holding costs
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Potential for reducing medical errors
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Engage patients in shared decision making
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Stressing accrual to Clinical Trials
Contracting Opportunities with Payers
• Gain Share on Savings
• $1,000 savings to payer is $15 from
practice, $485 from Pharma and
$500 from hospital
• Increase existing fee schedule
• RVU based services
• Drugs (advise against…)
• Extend current reimbursement rates
• Decrease Administrative Burden
• Eliminate pre-certs / prior auth /
Box 19 data
• Prevent Payer from pulling drugs
out of practice
• Specialty Pharmacy
• Infusion Centers
• Reverse rate decreases
• Payer Steerage to Practice
• Network Status
• Benefit design to allow for lower
copay/coinsurance
• Accept case/bundled rates
Why Gain Share is difficult…
• Difficult to measure – requires Payer to roll up costs from variety of
systems
• Results without statistical validity can give false negatives
• Long timeline for pilot followed by claims runout…then measurement
• Tends to be a “one year” phenomenon…hard to repeat savings!
• Payer Unique Issues
– Cancer is not their top priority…not even top 3
• Most don’t have the information to measure their total $pmpm for cancer
– Pathways are the proverbial “elephant in the room” – who at the Health
Plan has jurisdiction???
– Some believe that oncologists are already paid too much…
– They are not used to outsourcing “UM” to the providers themselves
Opportunities with Other Healthcare Entities
• Patient Centered Medical Homes (PCMH)
– Participate directly or become a preferred practice for referrals
• Design Hospital <=> Private Practice affiliation (co-management) incentive
structures through enhanced data capture and monitoring; benchmark
performance
• Form a clinically integrated network (CI) with other oncologists and
negotiate single payer contracts
• Accountable Care Organization (ACO)
– Participate directly or become a preferred practice for referrals
Why Pathways? Why Now?
Pathways are a proven model for tangibly demonstrating VALUE (Q/C)
to your key stakeholders (patients, referring MD’s, hospitals, payers)
in the new healthcare milieu
And retaining control over decision making for your patients…
Questions?
Discussion…