Transcript Cancer Care Delivery Reform: the payer*s perspective

Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Cancer Care Delivery Reform:
The Payer’s Perspective
Michael Kolodziej, MD, FACP
National Medical Director, Oncology Solutions, Aetna
We put people at the center
of everything we do
This presentation
outlines how we can help
members and providers
optimize cancer care
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The rising cost of cancer care is everyone’s problem
1000%
Cancer care
is the leading
edge of medical
cost trend
Cumulative
percentage
increase
$55 B
$123 B
Annual
increase
Cancer drugs
Cancer medical
Health care
0%
2010
1996
US GDP
20%
12-18%
9%
3%
www.cancer.gov/newscenter/pressreleases/2011/CostCancer2020
Aetna’s top
cost drivers in
cancer care
Medical Rx
Inpatient
Radiology
Specialist physician
30.8%
1.5 B
23.3%
1.1 B
22.4%
1.1 B
9.4%
483 M
*2010 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC
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Principles of our proposed strategy
• Drive efficient use of evidence-based medicine
– platform that provides content and workflows
– integrate into the Aetna and provider systems
– simplify the administrative processes for providers
• Avoid waste and misuse of medical services
– better provider alignment
(e.g., Oncology Patient Centered Medical Home),
– better network (narrow, tiered)
– better decision support strategies
• Leverage and integrate the many current (and future)
medical and pharmacy cancer-care initiatives
– seamless, end to end cancer experience for Aetna
members and providers
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Increased adherence to evidence based guidelines lowers
cost without negatively impacting treatment efficacy
Study: “Cost Effectiveness of Evidence-Based
Purpose: Evaluate the cost effectiveness of
Treatment Guidelines for the Treatment of
Non–Small-Cell Lung Cancer in the Community Setting”
evidence-based treatment pathways for NSCLC patients
Published: Journal of Oncology Practice (ASCO
Peer Reviewed Journal), 1/19/2010
patients according to evidence-based guidelines is a
cost-effective strategy for delivering care to those with NSCLC.
Significantly lowered cost in the
case group vs. The control group
No change in overall survival
between the study groups
Conclusion: Results of this study suggest that treating
Source: “Cost
Effectiveness of
Evidence-Based
Treatment Guidelines
for the Treatment of
Non–Small-Cell Lung
Cancer in the
Community Setting”.
Journal of Oncology
Practice. January
2010. Volume 6.
No.1. p 12-18
Overall survival by Pathway status.
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Medical management
Pathways and evidence based medicine
Clinical pathways are treatment roadmaps
of best care practices
• Developed through
research and
medical evidence
• Provide physicians a
more precise approach
to cancer care
• Pathway treatment
comparison
─ Efficacy
─ Toxicity (side effects)
─ Cost (utilizing generics)
• Pathway lines of therapy
─ Combination of drugs
used and the sequencing
of how they are given
─ Appropriateness of when
to begin treatment and
when to discontinue
treatment
─ A new line of therapy is
generally used when a
pathway did not meet
clinical outcomes or the
cancer progresses
Medical
management
model*
Customer
service
Communications
Network
design
Plan
design
Pharmacy
strategy
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Platform: Enable administrative easing
of prior authorization/pre-certification for
practices on the platform
Physician
accesses
vendor CDS
1
Pended via 278 transaction
Vendor
payer portal
iNexx Platform
eviti app
5
EBM
treatment
plan is built
2
3a
Automated
“CDS-code”
is delivered
Oncology
clinical decision
support
Vendor
clearing house
Locate CDS
code
information
etums/
ATV
Claims
processing
6
Enter CDS
code
information
3b
4
Email notification in near
real-time to Aetna UM
Local administrator
in claims processing
can be established
EDI
270/271
transaction
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What are the PCMH joint principles?
• Personal physician
— Each 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
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Expected benefits to health care consumers
• Improved health outcomes supported by doctors’ use of clinical decisionsupport tools to improve care management, tracking and adherence to
evidence-based guidelines
• 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
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Medical management
What about Oncology medical homes?
Define the components and
measurement criteria for designating
a provide practice as an Oncology
Medical Home (OMH).
Measurements would be those
defined initially by the Community
Oncology Alliance group such as:
Basic components include:
• Percentage of patients with documented
clinical or pathologic staging prior to
treatment
• Enhanced communication/patient
education
• Coordination and easy patient
access to care
• Percentage adherence to clinical pathways
• Percentage of ER visits per patient per year
• Case management responsibilities
• Percentage of Hospital admissions per
patient per year
• Improved patient tracking of compliance
to medications and follow up activity
• Percentage of patient deaths occurring in
an acute setting
• Reporting capabilities
• Average number of days in hospice prior to
death
• NCQA recognition
• Percentage of patients with stage IV that
have end-of-life care discussions
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We have the capabilities to equip oncologists with the tools to
transition to a medical home
Oncology Medical Home Solution
 Optimal Staffing Model to
provide leverage and
coordinate care
Financial Alignment
 Value based contracting
and benefit steerage to
drive adoption
Emerging Businesses
HIT Platform Patient Tools
Care Management Support
Provider Tools
Information Technology
 Clinical decision support tools
to optimize care plan
 Automated prior-authorization
to reduce administrative burden
 Oncology-tailored patient
applications to support
patients
 IT platform for care
transitions and holistic view
of patients
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Impact of a cancer management program:
an Innovent/Aetna pilot
Study Design
Location
Study period
•
Prospective, non-randomized evaluation of patients enrolled in the
Innovent Oncology Program
•
Patients seen by Texas Oncology physicians
•
Innovent Oncology Program 6/1/2010-5/31/2012; Program yr 1:
6/1/2010- 5/31/2011; Program yr 2: 5/1/2011-4/31/2012
•
Inclusion
•
•
•
Exclusion
•
•
Aetna eligible pts diagnosed with an Innovent diagnosis initiating
chemotherapy during program year 1 or year 2
Drug costs
ER and in-patient admissions and costs
Patient eligible for the program in the last month of each program
year
Patients with a chemotherapy claim in the month prior to the program
year
Patients without a chemotherapy claim within each program year
ASCO Quality, 2012
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Pathways Compliance
Nonassessable
4%**
Off-pathway
24%
On-pathway
76%
ASCO Quality, 2012
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Bundles are likely the end result
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18
Bach, Health Affairs, 2011
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We can also look to leverage ACS to serve oncology practices
seeking shared savings through an ACO model
B
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
Emerging Businesses
2 Aetna leverages ACS to facilitate
relationships between enabled
oncology practices and ACOs
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The goal
•Better quality
•Lower cost
•More value
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The current (sorry) state of affairs
The Oncologist and his/her office is stuck in a 20th Century communication and
Data exchange environment
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Focus on the patient
Place the patient at
the center of enhanced
care delivery facilitated
through the platform.
As practices invite other
providers to join their
collaboration network,
communication and services
around their patient’s
care are streamlined and
simplified.
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Privately or Publicly-Sponsored
Medicity Technology Connects Systems to Transform Data Into Action
Analytics, Clinical Decision Support,
Risk-stratified Populations & Quality
Measures
Patient Portal
Data Aggregation
Community Health Record
Identity Management
Bio Surveillance
Registries
Patient Consent Framework
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iNexx®
Result
Referral
Order
VCTR
iNexx® gives you the power to connect and create
the care delivery system that you want
Creating a more collaborative network of care givers
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Success will require multiple steps
1. Transformation of the clinical practice.
2. Evolution of the hospital into an integrated delivery
system.
3. Adoption of a culture that espouses performance
measurement and process improvement.
4. Modernization of the IT platform, focused on payer,
provider and patient integration.
5. Reformation of the reimbursement platform.
6. Partnership.
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