Transcript The Implications of Healthcare Reform on Cancer Care

Cancer Care Delivery in a Time
of Health Care Reform
Thomas W. Feeley, M.D.
US Health Expenditures: 1965-2017
$ billions
5,000,000
4,500,000
4,000,000
3,500,000
3,000,000
2,500,000
2.5 trillion dollars
2,000,000
1,500,000
1,000,000
500,000
0
1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
International Comparison of Spending on Health - 2007
From: Harvard Business Review, April 2010
International Comparison of Spending on Health 1980-2005
EXHIBIT 3
2009 – $8160
2009 – 17.3%
Average spending on health
per capita ($US PPP*)
$7,000
Total expenditures on health
as percent of GDP
16
United States
Germany
Canada
France
Australia
United Kingdom
$6,000
14
12
$5,000
10
$4,000
8
$3,000
6
$2,000
4
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
0
1984
$-
1982
2
1980
$1,000
United States
Germany
Canada
France
Australia
United Kingdom
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2007, Version 10/2007.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
61
Costs of Cancer Care
• NIH estimated the economic burden of cancer in
2010 to be $264 billion with $103 billion going
directly to cancer treatment
• Cancer care accounted for about 5% of health
care spending in 2009 and that percentage is
expected to increase
• Costs are rising due to drug costs, diagnostics
and procedure based therapeutics (molecular
diagnostics, advanced imaging, IMRT, proton
therapy, robotics)
Spending Attributed to Cancer 1990-2009
Elkin, E. B. et al. JAMA 2010;303:1086-1087
Rising Costs of Cancer Drugs
From: Bach PB: N Engl J Med 360:526, 2009
Presentation Aims
• How is cancer care affected by the American
Reinvestment and Recovery Act of 2009 and in
the Patient Protection and Affordable Care Act of
2010?
• How will health reform affect cancer care
delivery in different settings?
• What should providers be doing to prepare?
 Industry solution vs. government solution
 Focus on quality, value and competition
• What is happening in 2012 that may effect the
reform movement?
How is Cancer Care Addressed in the
American Reinvestment and Recovery
Act of 2009?
Recovery Act of 2009
• Two Key Provisions:
• Funding for Comparative Effectiveness
Research
 $1.1 billion allocated as of June 2011
 $109.5 million to NCI alone – additional funding
AHRQ and HHS exceeding CER funding for heart
disease
• HITECH Act component in bill to improve our
electronic interoperability
 Funding for Meaningful Use of Electronic Health
records
HITECH and Meaningful Use
•$2 billion – allocated
•Comments to CMS
realistic
From: Blumenthal D: Launching HITECH. NEJM 362:382, 2010
How is Cancer Care Addressed in the
Affordable Care Act?
The ACA and the Triple Aim
Don Berwick, former CEO of IHI and former CMS
Administrator - visionary with broad health
sector support and his view of reform is his
“triple aim”
1. Care coordination – integrated or coordinated
care
2. Population health – access, prevention and
early detection
3. Cost control
Cancer 2011;117:1564–74. April 16, 2011
The Affordable Care Act
• Access improved through insurance reform
mandating coverage, prohibiting preexisting
condition exclusions, maintaining renewability
• Delivery reform
 From specialty based care to primary care
• Reimbursement reform
 From rewarding volume and intensity to rewarding
quality and value – a balance between outcomes and
cost
Access to Health Care
Provisions
• Increased coverage of uninsured by about 32 million,
leaving about 23 million uninsured (about one-third are
unauthorized immigrants).
 The share of legal nonelderly residents with insurance coverage
would rise from about 83 percent currently to about 94 percent.
• Health insurance exchanges and increases in Medicaid
will provide the coverage
• Health insurers are likely attempting to build reserves –
contract renegotiations with decreased payments
• Focus for legislative and judicial challenges
What Else is in the Affordable Care Act?
Approaches to Delivery Models
• Patient-Centered Outcomes Research Institute –
an independent entity to advance quality and
relevance
• Center for Medicare and Medicaid Innovation –
a CMS branch to test new delivery and
reimbursement models new acting director –
Richard Gilfillan MD– use of evidence based
guidelines in cancer
• Accountable Care Organizations – primary care
• Patient Centered Medical Home – primary care
• Healthcare Innovation Zones – primary care
Patient-Centered Outcomes Research Institute
• PCORI will independently provide research for patients,
clinicians and purchasers to inform decision making
• Reliable information on health care choices through
contracted CER and dissemination of CER in
conjunction with AHRQ
• Began operating 2011 with governing board and bylaws
• Held first board meeting in May and also began public
hearings
• Funded through trust fund and budgets to spend $19.3
million in 2011
• HHS specifically prohibited from denying coverage due
to CER findings
Center for Medicare and Medicaid Innovation
• CMMI to test innovative delivery and reimbursement
models
• Established January 1, 2011 with Dr. Richard
Gilfillan as director
• First major effort was to develop language for
Accountable Care Organizations
• Specific directives in bill addressed use of evidence
based guidelines to direct payments for cancer and
development of Health Care Innovation Zones to
reimburse academic medical centers
• Testing of episode based payment plans
Center for Medicare and Medicaid Innovation
• Partnership for Patients launched by CMMI in 2011
 Providers, hospitals, patients aiming to prevent hospital
acquired conditions by 40% and reduce readmissions by
20% by 2013
 Would save 60,000 lives and aid 3.4 million patients in the
two programs
 Would save $35 billion dollars over 3 years and reduce
costs of Medicare by $10 billion
 Uses $1 billion from ACA for programs – half to test
models through contracts and half to improve community
transitions
Accountable Care Organizations
• Partnerships between hospitals and physicians
to coordinate and deliver efficient care (Fisher,
2006)
• Envisions legal agreements between hospitals,
primary care providers and specialists to
incentivize improved quality and slow the rise of
health care costs
• Included in ACA as a shared savings
demonstration program
Accountable Care Organizations
• Began January 1, 2012
• Legal and management structure to receive and share
savings
• Must employ sufficient primary care professionals to
treat minimum of 5000 beneficiaries
• 3 year minimum, evidence based medicine
• First proposed rules from CMI with many negative
comments
• Patients not excluded from specialty care for cancer
• Many major players not in – Mayo Clinic, Memorial
Hermann
• Pioneer Program introduced as well as first year
incentives
Accountable Care Organizations
• Key Questions:
 How do specialty hospitals and practices relate to
ACOs?
• Berwick – “practice triple aim”
• Gilfillan – “find good partners”
 What will happen to FTC and Stark provisions related
to integration of care between hospitals and
physicians?
 How many ACOs will form outside the federal
program? Many are planning
 Can we achieve care coordination, population health
and control of costs – Berwick’s Triple Aim – outside
an ACO structure?
Patient Centered Medical Homes
• There is a long history of medical homes or
health homes – introduced by American
Academy of Pediatrics in 1967
• Adopted as a primary care model by WHO in
1978
• The subject of hundreds of publications and
dozens of demonstration projects
Patient Centered Medical Homes
From: NEJM 362:1555, 2010
Patient Centered Medical Homes
• While these were originally described as primary
care delivery system and reimbursement
reforms several specialties claim to be the
medical home for their patients:
Patient Centered Medical Homes
From: Casalino, et al: Specialist physician practices as patient centered medical homes, NEJM: 362:1555, 2010
Patient Centered Medical Homes
Patient Centered Medical Homes
• Key Questions
 Cancer programs clearly can not be a traditional
PCMH for primary care
 Should you consider becoming certified as a specialty
medical home by National Committee on Quality
Assurance?
 Should cancer care programs simply declare and
describe the fact that we function as a PCMH?
Currently surveys of oncology programs ongoing.
Approaches to Reimbursement Models
• Shared savings through accountable care
organizations
• National pilots on payment bundling
 5 year assessment of care in hospitalization from three
days before to thirty days after
 While federal demonstrations not for cancer – please
watch carefully since private payers are very anxious to
pay for bundled care
 Cardiac care, orthopedics, transplantation, dialysis all
good fits
 Pressure to expand from private payers
How does the ACO Shared Savings Model Work?
Initial shared savings derived from spending below benchmarks:
There will be tremendous pressure not to refer outside an ACO
Why All the Interest in Bundled Payments?
FROM: Hussey PS et al: Controlling US health care spending – separating promising from unpromising
approaches. N Engl J Med 361:2109,2009
Bundled Payments for Cancer Care
• Cancer good candidate for bundling
• Must know your true costs of an entire episode
of care
• Bundling of cancer drug treatments
 Bach proposal to Medicare
 Newcomer pilot in United Healthcare
Bundled Payments for Cancer Care
•
From: Bach PB, et al. Episode based payment for cancer care. Health Affairs 30:500, 2011
Quality Initiatives
• Quality Reporting for Prospective Payment
System (PPS) Exempt Cancer Centers
• Quality Measures, Data Collection and Public
Reporting
• Pay for Performance Pilot for PPS-exempt
Cancer Hospitals
Quality Reporting for PPS-exempt Cancer
Hospitals
• For FY 2014 and beyond, PPS-exempt cancer
hospitals must submit quality data
• Not later than October 1, 2012, the Secretary
shall publish the measures selected.
• The Secretary shall report quality measures of
process, structure, outcome, patients’
perspective on care, efficiency, and costs of care
on the CMS website.
Section 3005
From: Spinks, et al. Health Affairs 30:664-672, 2011
Quality Reporting for PPS-exempt Cancer
Hospitals
Final List of PPS-Exempt Cancer Hospital Measures –
Currently Under Review by CMS and their consultants
Mathematics Policy Research and the NCQA:
•
Chemotherapy/hormone therapy measures (CoC/NCDB)

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•
Adjuvant chemotherapy for Stage III colon cancer
Combination chemotherapy for AJCC T1cN0M0 or Stage II or III hormone receptor
negative breast cancer
Hormone therapy for AJCC T1cN0M0 or Stage II or III hormone receptor positive
breast cancer
Hospital Acquired Infections (HAI) measures (CDC/NHSN)


Catheter-associated urinary tract infection (CAUTI)
Central line-associated blood stream infection (CLABSI)
All are current NQF measures but being modified for use
Next stage likely to include end of life measures
Quality Initiatives
• Quality Reporting for Prospective Payment System
(PPS) Exempt Cancer Centers by 2014
 First step in development of quality measures specific to cancer
care
• Pay for Performance Pilot for PPS-exempt Cancer
Hospitals by 2016
 Few details but expect reimbursement based on measure
reporting including payment for Hospital Acquired Conditions to
be features.
• Quality Measures, Data Collection and Public Reporting
 Plans for the development, collection, and public reporting of
quality measures for other providers
Additional Items of Significance
• Coverage for individuals in clinical trials
• Programs related to breast health education
• Laboratory demonstration project in molecular
diagnostics
• Value based purchasing for hospitals based on core
measures
• Quality improvement research programs
• Hospital readmissions
• Independent Medicare Advisory Board
• Professional education
• Enhancement of nursing retention programs
• Tanning and skin cancer prevention
Additional Items of Significance
• Disease prevention provisions
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National council
Task force
Media campaign
Wellness visits annually
Deductibles waived for colon Ca screening
State grants for tobacco cessation
Grants for community health and prevention
How Is MD Anderson Preparing for
Health Reform ?
A Value Based Approach
Patient
Centered
Outcomes
Value
Per
Capita
Costs
We must demonstrate the value
of our care delivery model
A Value Based Approach
• Understand our outcomes, report them
and strive to continually improve them –
survival and patient centric measures
• Understand our costs and strive to
control them
 Time driven activity based cost accounting –
(TDABC)
• A cost accounting built around the entire patient
experience
• Must build in cancer care the transparent
electronic systems that collect critical elements
of outcomes and costs for internal
improvement and external reporting
Outcomes Feasibility Study
• 2468 patients with laryngeal, oral and
oropharyngeal cancer
• Survival from tumor registry, ability to
speak and swallow from EMR
• Findings
 EMR required abstracting – meaningful
metrics not searchable
 Tumor registry required query
 Need to input data so it can be regularly
extracted easily
Costing Feasibility Study
• 2468 patients with laryngeal, oral and
oropharyngeal cancer
• Costs from charge based system
• Compare with time-driven, activity based
costing (TDABC) using new cohort
 Process map each patient encounter – first visit,
imaging, surgery, chemotherapy, etc
 Assign times and probabilities of elements and
match with personnel costs
 Calculate costs of episode or elements of an
episode as sum of process costs
Using Charges to Measure Cost
Center Line: Median
Shaded Box: Interquartile Range (25th-75th %ile
Extension Lines: 1.5x Interquartile Range
Dots: Costs falling outside extension lines
Using TDABC to Measure Costs
Using TDABC to Measure Costs
PSC completes paper
work and administers new
patient questionnaire
5
RN gathers vital signs,
reviews Preop
Questionnaire, Reconciles
ClinicStation Meds /
Allergies
Enters into PICIS - Meds,
allergies, demographics,
procedure, and completes
instruction and teaching.
20
N 80%
Are outside
records needed?
N 50%
Is an ECG
needed?
Will MD
evaluate
paitent?
Y 60%
MD evaluates
patient
Y 60%
N 95%
Is a consult
needed?
25
Y 20%
Y 50%
N 40%
Obtain records
Tech completes
the ECG
PA evaluates
patient
20
RN discharges
patient and gives
patient instructions
5
Patient leaves
Y 5%
10
Arrange for
consult, patient not
cleared for OR
25
25
Color Key
MD signs-off on
evalutation
PSC
10
Nurse
Tech
Before
Physicians
Assistant
Physician
PSC completes
paperwork and
administers new
patient
questionnaire 5
MA takes vitals,
finishes PASQ in
pre-op triage
N 80%
Is an ECG
needed?
Triage occurs?
10
Y 20%
Tech completes
ECG
N 70%
RN reviews
medical record,
patient
Questionnaire,
Performs Med Rec
15
in CS
Are outside
records
needed?
N 70% PA/MD conducts
evaluation
Y 30%
Complete
evaluation,
medical record
Obtain records
10
15
N 95%
Is a consult
needed?
25
N 30%
20
RN discharges
patient and gives
patient instructions
Patient leaves
5
Y 5%
Arrange for consult
25
Patient leaves
Color Key
PSC
Nurse
Tech
PA/MD
36% reduction in per patient cost – not visible in existing
charge based cost accounting system
After
Using TDABC to Measure Costs
• Compare with TDABC using new cohort
 Mapping over 160 individual elements ongoing
 Preliminary finding - some processes not billable but




have costly labor – i.e. multidisciplinary planning
conferences
Building first set of maps challenging – subsequent
mapping simpler
Electronic solution needed to link maps, general ledger
data and human resources data – available but
untested in health care
Results will enable pricing based on true costs
Will alsopermit better understanding of effects of
performance improvement on true costs
What is in the News About the Health
Reform?
Challenges to ACA in 2012
• Supreme Court
 Will happen in spring of 2012
 Will have influence on 2012 election – how unknown
• Elections of 2012
 Republicans calling for repeal
 What could that mean?
• States issues in 2012
 Legislative sessions – wildcards
 Governor and representative elections in 2012
Challenges to ACA in 2012
• Supreme Court – The Case
 Will hear case March 26-28, rule late June early July
 30 suits in 26 states
 Court will hear Florida v US decision by 11th Circuit in
Atlanta – only Federal Court to strike the individual
mandate as unconstitutional
 Focus on 4 areas
• The individual mandate
• Medicaid expansion
• Tax law violation – Anti-Injunction Act cannot challenge a tax
until it is filed - 2015
• Severability
Challenges to ACA in 2012
• Supreme Court – Possible Outcome
 Law upheld in its entirety
 Strike individual mandate or Medicaid expansion – will need to
go against precedent due to lack of severability clause in ACA
 Complete repeal of ACA – could happen if individual mandate or
Medicaid expansion ruled unconstitutional and the lack of a
severability clause in legislation meant whole bill would be
repealed
 Delay to 2015 on grounds that the Anti –Injunction Act bars any
challenges until 2015 when the “tax” goes into effect
• Court composition
 4 conservative (against) – 4 liberal (pro)
 Anthony Kennedy – moderate may be key in decision
Challenges to ACA in 2012
• Elections of 2012
 Presidential election and control of Congress critical
determinants – extreme uncertainty
• Republican control – Congress and Executive – repeal likely
• Obama and Republican Congress – veto of repeal
• Status Quo – no change but continued legislative challenges
to funding the bill implementation
• Democratic control – full implementation through 2016
Conclusions
•
•
•
•
Health care delivery reform will happen
Legislation is a guide, not a road map
Industry needs to take the lead in reform
A value-based cancer care delivery system that
is effective, efficient, accessible and affordable is
essential for the future health of our nation