Transcript PPT Feb 24 1130A Oncologys Role

Oncology’s Role In
Population Health
Ira M. Klein, MD, MBA, Janssen
Pharmaceuticals
Robert Kropp, MD, Aetna
Harlan Levine, MD, City of Hope
Kavita Patel, MD, Brookings Institution
Kelley D. Simpson, Oncology Solutions LLC
Presentation Map
Kavita Patel, M.D., MS,
Managing Director for Clinical Transformation & Delivery
Engelberg Center for Health Care Reform Studies
Brookings Institution
Kelley D. Simpson, Senior Partner
Oncology Solutions, LLC
Practical
Application
Present
& Future
Trends
Robert Kropp, M.D.
Regional Medical Director, Aetna
AMC’s
Role in
PHM
Accountable
Care
Solutions
Triple
Aim
Harlan Levine, MD
Chief Executive, City of Hope Medical Foundation
Associate Director for Community Initiatives
Comprehensive Cancer Center
Ira Klein, MD, MBA, FACP
Senior Director, Health Care Quality Strategies
Johnson & Johnson Health Care Systems Inc.
1
Including Oncology in the
Triple Aim Goals of Care
Ira Klein, MD, MBA, FACP
Senior Director, Health Care Quality Strategies
Johnson & Johnson Health Care Systems Inc.
4
Today, still mostly in a FFS world
Fundamental change requires increased collaboration and
aligned incentives for oncologists re-organize into population
health management
PPO
Today
Performance
based
networks
PatientCentered
Medical
Home
Institutes
of Quality
Accountable
Care
Organization
Tomorrow
Broad-based
access to care
delivery
Total population
health management
All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems
Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson
5
Private Market ACO formation matches CMS goals to
address population health management
SGR fix/MACRA
Triple Aim Goals
Insightful Analytics
Measureable Clinical Outputs
ACO Management Plan
Pop. Health in a new APM World
All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems
Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson
6
The NQS approach to guide efforts to improve
health and the quality of health care
3 Goals
6 Priorities
Performance
Programs
Payers
Providers
Hospitals/IDNs
ADOPT
FOCUS
INCENTIVIZE
Provide better, more
affordable care for the
individual and the community
Guide efforts to improve
health and health care
quality
Incentivize stakeholders
through Accountable Care
Organizations (ACOs) and
Bundled Payments
All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems
Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson
7
NQS “Priorities” represent 6 quality domains
used by CMS to drive value based care
Priority/Domain
Clinical Care
Definition
Sub-domains
Promoting the most effective prevention and
treatment practices for the leading causes of
mortality, starting with cardiovascular disease
• Appropriate Use
• Clinical
Outcomes/Intermediate
Outcomes
• Medication Adherence
• Patient Reported Outcomes
• AHRQ CAHPS – Patient
Experience of Care
• Shared Decision Making
• Care Plan Creation
• Patient Activation
Patient Experience
Ensuring that each person and family members
are engaged as partners in their care
Population/
Community Health
Working with communities to promote wide use of
best practices to enable healthy living
• Screening/Preventive
Services
Making care safer by reducing harm caused in the
delivery of care
• Health Care Acquired
Conditions
• Potentially Avoidable
Complications
Patient Safety
Care Coordination
Total Overall Costs
Promoting effective communication and
coordination of care
Making quality care more affordable for
individuals, families, employers and
governments by developing and spreading
new healthcare delivery models
• Communication of Care Plan
• Hospital Readmissions
• Medication Reconciliation
• Global/Capitated
Costs/Medicare Spending
Beneficiary
• Episode of Care Costs for:
- Acute & 3 - Chronic
Conditions
3
All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems
Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson
8
The ACO Management Plan for Cancer Care:
Population Health based Oncology Activities
Objectives:
• Analyze the cancer
population characteristics
• Analyze the cancer medical
cost spend
• Analyze the medical quality
and cost improvements in
key measures that would be
needed to sustain the
business model
Tools:
•
Efficiency Modeling from Oncology Solutions
•
Sections include:
– Demographics
– Disease specific profiles
– Outlier profiles
– Costs by type of service
– Inpatient Detail
– Inpatient by Admit Type
– ER
– Radiation Oncology
– Outpatient procedures
– Lab
– Radiology
– Pharmacy
– Hospice/Palliative care
•
Have an Efficiency Model Tab:
– What If scenarios for variable degrees of
improvement in utilization
– Benchmarks against national best in class,
industry or size/demographics/risk comparison
groups.
All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems
Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson
9
Accountable Care Solutions
from Aetna
Robert Kropp, M.D.
Regional Medical Director, Aetna
10
The Academic Medical Center’s
Role in Population Health
Harlan Levine, MD
Chief Executive, City of Hope Medical Foundation
Associate Director for Community Initiatives
Comprehensive Cancer Center
18
Academic Medical Center’s Role in Population Health
Basic Science & Discovery
Research & Teaching
Drive Next Generation Care Protocols
Complex, Highly Technical Services
Patient Centered Coordinated Care
survivorship
primary care system
end of life,
palliation
Specialty Population Health
Population
Health
Oncology
• Narrow Networks
• Primary Care
• Personal Accountabilities &
Behaviors
Some fit, but differences:
High cost, uncommon, moderate
complexity
High cost, rare, highly complex
Rapid changes in standard of care
Niche expertise matters
Accountable Health System
Academic Medical
Center Obligation
• Deliver care cost effectively
• Advance the field
Health System
Obligation
• Allow access to expertise
• Compensate based on
complexity
Joint
Accountability
• Coordinate patient care
• Measure outcomes that matter
Challenges that must be overcome
• Deploying rational risk bearing models
– Risk assumption not created for low frequency, high cost
events
– Case rates are problematic when there is high variability in
cost
• Acknowledging that Treatment and Diagnostics are evolving
and fall into three categories: Proven, Unproven and
Common Sense
• Defining the optimal care model: Tension between bundling
and fragmentation of care
• Managing the high cost of medications
• Identifying measures that matter—Value~Outcomes/(Cost X
Time)
Present and Future Policy Trends
in Population Health to Oncology Care
Kavita Patel, M.D., MS,
Managing Director for Clinical Transformation & Delivery
Engelberg Center for Health Care Reform Studies
Brookings Institution
23
Practical Application
of Oncology-Specific Tools
Kelley D. Simpson, Senior Partner
Oncology Solutions, LLC
24
PHM Integration Challenges for Oncology
•
•
•
•
•
•
Increasing difficulties with timely access to primary care providers—wait times for
appointments can be months in many health systems
The primary care provider pool seldom “rubs elbows” with oncology providers
causing a divide of information exchange and knowledge transfer
Primary care providers are managing ever-increasing patient populations and are
expected to acknowledge the “latest and greatest” prevention, screening and
diagnostic work-up guidelines for a range of diseases (and, by the way, there are
100+ different types of cancer)
Collaboration with a range of oncology and oncology-related providers, both
employed and independent, fractures care coordination
Information/EHR data exchange presents great limitations, particularly with
independent oncology providers but also within captive physician networks where IT
interfacing/integration is often stymied
Genetic profiling and testing standards as well as national screening guidelines are
swiftly changing patient assessment procedures—in Dr. Levine’s context these are
”proven, unproven or common sense”
Landscape of PCP Oncology-Related Involvement
•
•
•
•
PCPs primarily involved
with cancer screening and
detection activities
Post diagnosis, the patient
is referred to the oncology
team and the PCP falls out
of the loop as time
passes—many times it is
up to the patient to ensure
information exchange
PCPs play mostly a comanagement role for
comorbid conditions,
treating depression and
pain management
Some trending to involve
PCPs more actively in
survivorship care
J Gen Intern Med. 2009 Sep; 24(9): 1029–1036.
The Role of Primary Care Physicians in Cancer Care
Carrie N. Klabunde, PhD, corresponding author Anita Ambs, MPH, Nancy L. Keating, MD, MPH, Yulei He, PhD,
William R. Doucette, PhD, Diana Tisnado, PhD, Steven Clauser, PhD, and Katherine L. Kahn, MD
An Oncology Led Strategy
•
The cornerstone of population health management (PHM) is clinical decision
making supported by evidence-based standards of care powered by real-time
analytics
–
This philosophy is in direct alignment with the Oncology Care Model and Patient-Centered Oncology
Medical Home but focused exclusively on the cancer/cancer-related patient population from
prevention, screening and early detection through end-of-life and survivorship care planning
•
With respect to oncology populations, oncologists are considered the “primary
care” physician so…how can this knowledge transfer support primary care
providers within the PHM eco-system?
•
One of the most effective strategies employed is cross-pollination of primary care
providers within oncology disease-specific Clinical Performance Groups (CPGs) that
set pathways by disease across the full cancer care continuum—triage, screening,
diagnostics, treatment and EOL or survivorship care
–
Oncologists’ vast experience managing high-risk populations within a multi-d, patient-centered
model of care spanning years is of great benefit to any overarching PHM program
Oncology-Specific Elements Influencing PHM
• CoC Community Health Needs Assessment (CHNA) to address:
–
–
–
–
–
The cancer program’s community and local patient population
Health disparities
Barriers to care: patient-centered, provider-centered, or health system-centered
Resources available to overcome barriers on-site or by formal referral
Gaps in the availability of resources to overcome barriers
• Cancer focused community outreach and screening initiatives
• Clinical Performance Group alignment with primary care, resulting in tools to
support an overburdened primary care provider pool
• High risk population management
• Survivorship care management
Primary Care Participation Essential for Multi-D Lung Program Development
01
PCP Participation
Within Lung Cancer
Clinical Performance Group
BASELINE ASSESSMENT AND GOAL IDENTIFICATION
• Developed Community Needs Assessment in collaboration with
Program Director and Registrar
• Identified gaps in existing services and barriers to access
• Developed goals for lung cancer education, screening, work-up
and referral parameters
PATHWAY DEVELOPMENT AND PCP INSIGHT
•
•
•
•
•
•
Pathology
Radiology
Primary care
Thoracic surgery
Pulmonology
Medical oncology
•
•
•
•
•
•
02
Radiation oncology
Cancer care navigation
Cancer program director
Tumor registrar
Clinical research
IT and marketing reps
• Participated in development of pathways:
 Clinical presentation and risk assessment
 Findings and follow-up
 Navigator intervention and PCP communication
• Recommended avenues for PCP education/marketing
and direct-to-consumer marketing
• Identified tools needed to ”make life easier” for the PCPs
LUNG CANCER TOOLS AND COMMUNICATION
03
• Helped draft and finalize LDCT screening materials
 Physician Preference Profile Form with reverse page outline of
NCCN guidelines
 Lung cancer screening algorithm
 Navigator intervention and PCP communication algorithm
 Phone Scripting and Intake Form
 Lung cancer program dashboard/metrics
 Letter to targeted high risk patient population
• Assisted with designing IT form in PCP network EHR
• Communication plan for education to broader PCP network
SAMPLE
Lung Cancer
Screening Algorithm
SAMPLE
Phone Scripting and Intake Form
Date of Baseline CT:
Age at Baseline:
Occupation:
Level of Education:
Sex:
Male
Female
Weight:
Height:
Do you currently smoke?
Yes
No
SAMPLE
Physician Preference Profile Form
Comprehensive Lung Program Physician
Preference Profile
Ethnicity:
History of Smoking:
BMI:
How many cigarettes smoked per day?
Has a physician ever told you that you had COPD, emphysema, bronchitis, or pneumonia?
Pneumonia
Bronchitis
Emphysema
COPD
If yes, which one(s)?:
Have you ever had any type of cancer (excluding basal or squamous cell skin cancer?
If yes, list type of cancer(s):
Have any of your immediate family (parents, siblings or children) had lung cancer?
Have you had prolonged exposure to second hand smoke?
Yes
No
Yes
No
If you quit, has it been less than 15 years ago?
What is the total number of years you have smoked?
Date:
Date of Birth:
Yes
No
Yes
No
Yes
No
You have agreed to allow OHS to maintain a preference profile on record. This profile allows the OHS radiologists to
schedule all necessary follow-up activities to complete a diagnosis for your patients.
1. You HAVE
Date:
agreed to allow OHS to keep a preference profile on record.
Biopsy
Percutaneous needle biospy
Bronchoscopy
SuperDimension iLogic bronchoscopy
All of the above
3.
To your knowledge have you been explosed to radon, silica, cadmium, asbestos, arsenic, beryllium, chromium, diesel
No
Yes
fumes, or nickel?:
or HAVE NOT
2. If my patient’s lung screening is ACR LungRADS category 4A, 4B, 4X, S or C, please proceed with the OHS Lung
Screening Program’s standardized diagnostic work up to include as indicated and appropriate (check all that apply):
If so, please explain:
You may have exposure to especially hazardous chemicals if you have engaged in any of the following occupations. Please
mark any that apply.
Sandblasting
Manufacturing
Painter
Printer
Asbestos worker
Uranium mining
Drywall
Bartender
Metal worker
Ceramic worker
Masonry worker
Chemist
Truck driver
Glass worker
OMC Clinical Staff Review By:
Please indicate your patient care preferences below. These preferences will be kept on record at all Olathe Health
System Screening and Diagnostic locations to be utilized for any patients that you refer for lung screening. If you have
any questions or wish to make any changes to these preferences, please contact the Nurse Navigator at OMC at
(XXX) XXX-XXXX. Thank you for your participation with improving the quality and continuity of care provided to
patients at OHS.
Yes
No
Please check below any new respiratory symptoms
that have appeared in the last 6 months:
Shortness of breath
Cough
Coughing up blood
Wheezing
Primary Physician Name:
Your preferences do not constitute an order set for
additional views or tests. This information will be utilized
to allow the Lung Nurse Navigator to streamline the
process of contacting your office for an order and
coordinating patient scheduling for follow-up procedures.
If a consult is required, please choose from the below preferences for patient referral:
a. You prefer your patient choose a pulmonologist or surgeon for consultation.
b. Please call the primary care physician office for patient referral to a pulmonologist or surgeon.
c. You prefer to have your patient see Dr.
or
pulmonology or surgical group for any necessary consult, if covered by the patient’s insurance.
c.(i) If a consult is required and your preferred pulmonologist or surgeon is not available within a
reasonable timeframe or is not covered by the patient’s insurance, you request to have your patient
seen by:
Dr.
or
if covered by the patient’s
insurance.
You prefer your patient choose a pulmonologist or surgeon/group for consultation.
4. You agree to allow:
The Lung Nurse Navigator to provide normal findings to your patient.
The radiologist to provide results of abnormal diagnostic tests to your patient.
The pulmonologist or surgeon to provide results of any pathologic test to your patient. A Lung Nurse
Navigator will be present to provide an understanding of the next steps in the process… OR
You request the patient receive any abnormal or positive diagnostic test results from you, the PCP.
References: Journal of National Comprehensive Cancer Network Volume 10, Number 2, February 2012. Lung Cancer Screening.
Physician Signature:
Date:
SAMPLE
Physician Preference Profile Form
SAMPLE
Physician Preference Profile Form
Comprehensive Lung Program Physician
Front Page: PCP Completion
GUIDELINES
FOR
Reverse Page: NCCNNCCN
Follow-Up
Screening
Guidelines
Preference Profile
Date:
nd
Primary Physician Name:
2 Screening
Please indicate your patient care preferences below. These preferences will be kept on record at all Olathe Health
System Screening and Diagnostic locations to be utilized for any patients that you refer for lung screening. If you have
any questions or wish to make any changes to these preferences, please contact the Nurse Navigator at OMC at
(XXX) XXX-XXXX. Thank you for your participation with improving the quality and continuity of care provided to
patients at OHS.
You have agreed to allow OHS to maintain a preference profile on record. This profile allows the OHS radiologists to
schedule all necessary follow-up activities to complete a diagnosis for your patients.
1. You HAVE
or HAVE NOT
Biopsy
Percutaneous needle biospy
Bronchoscopy
SuperDimension iLogic bronchoscopy
All of the above
Your preferences do not constitute an order set for
additional views or tests. This information will be utilized
to allow the Lung Nurse Navigator to streamline the
process of contacting your office for an order and
coordinating patient scheduling for follow-up procedures.
If a consult is required, please choose from the below preferences for patient referral:
a. You prefer your patient choose a pulmonologist or surgeon for consultation.
b. Please call the primary care physician office for patient referral to a pulmonologist or surgeon.
c. You prefer to have your patient see Dr.
or
pulmonology or surgical group for any necessary consult, if covered by the patient’s insurance.
c.(i) If a consult is required and your preferred pulmonologist or surgeon is not available within a
reasonable timeframe or is not covered by the patient’s insurance, you request to have your patient
seen by:
Dr.
or
if covered by the patient’s
insurance.
You prefer your patient choose a pulmonologist or surgeon/group for consultation.
4. You agree to allow:
The Lung Nurse Navigator to provide normal findings to your patient.
The radiologist to provide results of abnormal diagnostic tests to your patient.
The pulmonologist or surgeon to provide results of any pathologic test to your patient. A Lung Nurse
Navigator will be present to provide an understanding of the next steps in the process… OR
You request the patient receive any abnormal or positive diagnostic test results from you, the PCP.
Physician Signature:
•
•
•
Date:
Nodule <6mm, LDCT in 12 mos.
Nodule 6-8mm, follow up LDCT in 3 mos.
Nodule >8mm PET/CT
nd
After 2 Screening
• Nodule 6-8mm with no increase in size, follow LDCT up in 6 mos. No increase, then yearly.
Increase in nodule at 6 mos., surgery
• Nodules >8mm, likely not cancer, follow up LDCT in 3 mos. No increase, LDCT in 6 mos.
No increase, then yearly. If increase at 6 mos., consider surgery
• Nodule >8mm, maybe cancer, refer for biopsy or surgery
agreed to allow OHS to keep a preference profile on record.
2. If my patient’s lung screening is ACR LungRADS category 4A, 4B, 4X, S or C, please proceed with the OHS Lung
Screening Program’s standardized diagnostic work up to include as indicated and appropriate (check all that apply):
3.
LUNG SCREENING
nd
2 Screening
•
•
•
Nodule <5mm, LDCT in 12 mos.
Nodule 5.1 to 10mm in width, follow up LDCT in 6 mos.
Nodule >10mm in width, follow up in 3 mos.
nd
After 2 Screening
•
<5mm in width, no increase, follow up LDCT in 12 mos. If increase, LDCT in 3-6 mos. or consider
surgery
5.1 to 10 mm in width, no increase, follow up LDCT in 12 mos. If increase surgery
>10 mm in width, no increase, LDCT in 6 -12 mos. If increase biopsy or consider surgery
•
•
nd
2 Screening
•
•
•
Non-solid nodules <5 mm in width, follow up LDCT in 12 mos.
At least one non-solid nodule >5mm in width, follow LDCT in 6 mos.
One or > dominant nodules with solid or part-solid portion follow LDCT in 3-6 mos.
nd
After 2 Screening
•
•
•
All non-solid nodule, no increase, follow up LDCT in 12 mos. If increase, another
LDCT in 3 – 6 mos. or consider surgery
At least one nodule is >5mm, no increase, follow up LDCT in 12 mos. If increase, surgery
Dominant nodules with solid or part solid portion, decrease, follow up in 12 mos. If same or
increase see recommended care for solid or part solid nodule.
Infection/Inflammation or Cancer
•
Follow up LDCT in 1-2 months after treatment for infection/inflammation
After Follow Up LDCT for Infection/Inflammation or Cancer
•
•
•
•
Nodule gone, follow up LDCT in 12 mos.
Nodule smaller, follow until nodule gone/stops shrinking, follow up LDCT in 12 mos.
Nodule same size or >, > 8mm, PET/CT, if not likely cancer, follow up LDCT in 3 mos.
Nodule same size or larger >8mm, maybe cancer, refer for biopsy or surgery
Source: National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.
Lung Cancer Screening, version 2.2014.
SAMPLE
Letter to High Risk
Patients in the
Community
New Low-Dose CT Lung Screening Program
Early detection saves lives. It could save yours.
Dear <Patient Name>,
I’m proud to share with you that Medical Center is now offering a Low-Dose CT Lung Screening program. The purpose
of this program is to save lives by detecting lung cancer early, when it is easier to treat. An annual low-dose CT scan is
one of the most effective ways to detect early-stage lung cancer, before symptoms start to occur.
As the Lung Nurse Navigator, I work closely with the physicians of Medical Center. Together, we want to make you
aware of this new program. Based on a review of your health records, you may be a candidate for the screening.
WHO SHOULD GET A LOW-DOSE CT LUNG SCREENING?
Candidates for low-dose CT lung screenings should meet the following criteria.
 Ages 50-74 years old
 History of heavy smoking
 Either current smokers or smokers who have quit within the past 15 years
Additional risk factors include:
 Having cancer in the past
 Having emphysema or pulmonary fibrosis
 Having a family history of lung cancer
 Exposure to certain substances, including asbestos, arsenic, beryllium, cadmium, chromium, diesel fumes,
nickel, radon, silica and uranium.
HOW IS THE SCAN PERFORMED?
A low-dose CT lung screening is a scan that produces a 3-D image of the lungs. The scan takes less than 10 seconds. No
medications or needles are used. You can eat before and after the exam.
HOW MUCH DOES THE SCREENING COST?
There could be an out-of-pocket cost of $XXX for this screening; however, it is covered by some insurance companies.
Please contact me if you have any questions about cost and insurance coverage.
HOW DO I SCHEDULE OR LEARN MORE?
Please call me, Jane Doe, Lung Nurse Navigator, at XXX-XXX-XXXX. I can answer your questions, talk through the
required criteria and help you schedule a screening. I also welcome you to discuss this with your primary care doctor
at your next appointment.
Sincerely,
Lung Nurse Navigator
Medical Center
Oncology’s Role In Population Health
Questions?
Thank You for Your Interest
Ira M. Klein, MD, MBA [email protected]
Robert Kropp, MD [email protected]
Harlan Levine, MD [email protected]
Kavita Patel, MD [email protected]
Kelley D. Simpson [email protected]