Transcript OMH(MK)v2x
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Aetna’s Oncology Medical Home Pilot Michael Kolodziej, M.D., FACP National Medical Director, Oncology Solutions Aetna Our values guide our approach to creating a better health care system Our cause To make quality health care more affordable and more accessible Our strategy To be the global leader in empowering people to live healthier lives 2 Cancer is the most costly medical item, increasing at 2-3x the rate of other costs 1000% Cancer care is the leading edge of medical cost trend 0% Cumulative percentage increase 1996 Aetna's top cost drivers in cancer care $55 B Annual Increase $123 B Cancer Drugs 20% Cancer Medical 12-18% Health Care 9% US GDP 3% 2010 Medical Rx Inpatient Radiology Specialist Physician 30.8% 23.3% 22.4% 9.4% $1.5B $1.1B $1.1B $483M *2010 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC www.cancer.gov/newscenter/pressreleases/2011/CostCancer2020 3 Privileged and Confidential The health care system produces $750 billion in yearly waste Prevention failures Unnecessary services 7% 27% Fraud 10% U.S. health care 14% system waste 25% Excess administrative costs ~30% Inflated prices 17% of health spending is waste Inefficient care delivery Source: Institute of Medicine; 2009 data 4 As community oncologists migrate to hospital systems, cost increases • 172 clinics closed • 323 practices struggling financially • 44 practices sending ALL patients elsewhere for treatment • 224 practices acquired by a hospital • Source: COA Practice Impact Tracking Database 102 practices merged/acquired 5 What are the PCMH joint principles? • Patient has an ongoing relationship with a personal physician ― Personal physician leads a team of individuals that takes responsibility for the ongoing care of patients ― Personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals • Care is coordinated across health care system • Quality and safety are hallmarks of the medical home • Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication • Payment recognizes the added value provided to patients who have a patient-centered medical home 6 Expected benefits to health care consumers • Improved health outcomes • Reduced hospitalizations and ambulatory care ― Includes primary and readmissions ― Includes sensitive specialty/facility and other costs • Improved transition of care • Shared decision-making • Increased engagement in preventive health and wellness 7 8 How does this apply to oncology? • • • • • • Evidence-based medicine Enhanced access Shared decision making Coordination of care Quality reporting Payment reform 9 Privileged and Confidential 10 Results on evidence-based medicine adherence Pre-Pilot Baseline Adherence Pilot Group Adherence For every 100 patients treated in 6 oncology practices in the 6 months prior to using the clinical decision support system, 62 received an evidenced based treatment plan For every 100 patients treated in 6 oncology practices when using the clinical decision support system during the pilot, 87 received an evidenced based treatment plan Patient receiving an evidence based treatment plan Patient receiving a non-evidence based treatment plan • Our study showed a 43% relative improvement in adherence to evidence based treatment selection. • Peer-reviewed, published evidence-based treatment options, sourced from leading oncology guideline bodies such as the American Society of Clinical Oncology and the National Comprehensive Cancer Network, were selected for 25 more patients for every 100 cancer patients in our study. 11 Adherence to evidence-based medicine, by cancer type Results exceeding our expectations Across the board, our hypothesis was confirmed relative to increased adherence to EBM Baseline adherence data on more than 200 patients was pulled from chart review of 5 practices for the 6 month period prior to the start of our pilot. We compared our study group of 103 patients against this baseline data, examining changes in evidence-based adherence. In total, the absolute increase was 25%, a 43% relative increase. Pre-/Post- Study Comparison in Adherence to Evidence Based Medicine 100% 100% 91% 87% 79% 79% 75% 89% 89% 79% 69% 62% 61% 51% 50% Baseline Study 0% 25% 0% Study Sample Size Total Colorectal Breast Lung Lymphoma Other 103 28 22 18 8 27 12 Pathways require… • Evidentiary and operational process • Measurement and reporting 13 Privileged and Confidential Pathways are derived from focus on high-quality, cost-effective regimens Eligible for instant authorization Eligible for instant authorization Eligible for instant authorization Eligible for instant authorization Eligible for: Instant authorization Quality Performance Plan 14 15 16 17 17 18 18 Clinical decision support options 19 20 ER use by chemotherapy patients Milliman Analysis of Medstat 2007, 14 million commercially insured lives, 104,473 cancer patients, Milliman Health Cost Guidelines 2009, Fitch K, Iwasaki K, Pyenson B. Cancer Patients Receiving Chemotherapy: Opportunities for Better Management. March 30th, 2010, Milliman 21 Inpatient use by chemotherapy patients Milliman Analysis of Medstat 2007, 14 million commercially insured lives, 104,473 cancer patients, Milliman Health Cost Guidelines 2009, Fitch K, Iwasaki K, Pyenson B. Cancer Patients Receiving Chemotherapy: Opportunities for Better Management. March 30th, 2010, Milliman 22 ER visits per chemotherapy patient have dropped by 70 % since 2005 Source: Dr. John Sprandio. Reused with permission. Do not distribute. 23 Hospital admits per chemotherapy patient have dropped by 50 % since 2007 Source: Dr. John Sprandio. Reused with permission. Do not distribute. 24 How do you accomplish this? • Triage reform • Extended office hours • Patient education 25 Privileged and Confidential 26 Privileged and Confidential 27 28 Deliverables Patient summary, informed consent and medication sheets 29 Via OncologyTM Pathways’ Treatment Plan • Auto-generated for both onand off-Pathways decisions • Contains state/stage of Dx, treatment details, risks, monitoring plan, etc. • Can be edited, printed and saved within Pathways • Contents can be securely sent real time to EMR, practice staff and payers • Customizable by practice 30 Via OncologyTM Pathways’ Treatment Plan Summary • Auto-generated at end of Tx – State/stage of disease – Actual treatment delivered • Can be edited, printed and saved within Pathways • Pre-populated with Survivorship Pathways (includes Surveillance Plan) • Ability to display: – Response, reason for stopping – Actual toxicities and hospitalizations • Customizable by practice 31 Quality reporting: clinical process measures • Adherence to evidence-based treatment guidelines (including treatment exceeding lines of therapy and documentation of off-Pathways reasons) • Cancer staging • Performance status • Pain assessment • End-of-life metrics (ACP documentation, hospice enrollment, hospice length of stay) • Patient satisfaction 32 Quality reporting: financial measures These measures form the basis for the shared savings calculation: • ER visits (and costs) • Hospitalization rate (and costs) • Chemotherapy costs 33 34 Analytics: goals of process • • • • Standardize practice benchmarking Identify opportunities for improvement Form basis for shared savings Communicate 35 Our analytics process 1. Identify eligible patients by TIN/state or ZIP code 2. Initial ICD-9 with initial J code 3. “Group” claims using Aetna standard methodologies (cost categories) 4. Standardized query: opportunity to change single variable 36 ER and hospital: index practice ER IP IP LOS Breast (n=52) 29 24 3.7 Colon (n=14) 14 21 8 Lung (n=24) 18 31 5.4 Total 61 76 5.6 37 Chemotherapy costs N ME CP Breast 52 28325 25307 Colon 14 28819 38616 Lung 24 19576 17892 38 Reimbursement models • • • • • Management fee Enhanced fee schedule S codes Implementation fee Shared savings 39 S codes • • • • Treatment plan End-of-treatment summary Advanced care plan Oral chemotherapy management fee 40 Success requires participation • • • • • Enroll as many patients as possible Learn from your peers Work smarter, not more Trust us as a partner Remember, we are learning with you 41 Enablement of oncology-specific component for ACOs Text Hospital Oncology MH solution + Text Oncology Practice ACO Text Payor Community Oncology Practice Text Primary Care Practice 1 Aetna contracts with community oncology practices to become medical homes 2 Aetna leverages ACS to facilitate relationships between enabled oncology practices and ACOs 42 43 Aetna OMH network This could be you 44 Thank you 45