engaging physicians &patients in cost effective, high ...md... · patient centered value based...

Value Based Care Transitions:

Engaging Physicians &Patients in

Cost Effective, High Quality Cancer Care

Linda D Bosserman, MD, FACPClinical Assistant Professor

Medical Oncology & Oncology Medical HomeCity of Hope Medical Group

[email protected]

Patient Engagement-A New Day

� Tuesday 2-17-15 Morning Email

� PT: ‘Something New” 6:49am

� ME: Impression/Plan: 7:35am

� PT: Understanding of Plan 8:18am

� PT: Gratitude & how are labs?

9:31am

� ME: Clinic started 9:00 am

� PT: Feedback likely today

Changing Patient Engagement• The connected patient

• MU-Portals

• New devices

• New real time

connectivity & care

• Gathering PROs

• Apps

Lichter OBS 2014

What Do We Know from Patients?

Alston C et.al. IOM 2012

5

ENGAGEMENT WILL TAKE TIME &

FOCUS

EDUCATION/ADHE

RENCE

EDUCATION

REPORTING

SURVIVORSHIP

CLINICAL TRIALS

REMINDERS

DOCTOR DASHBOARD

PHYSICIAN EDUCATION

MOBILE APP

+ PATIENT

REPORTED

OUTCOMES

REAL TIME ALERTING

ACTIVATION SCORES

BEVAVIOR

REPORTING

CARE

MANAGEMENT

NAVIGATION

NURSE INTERVENTIONS

PATIENT CENTERED

CARE

ENGAGEMENT

PA

TIE

NT

SP

RO

VID

ER

S

TRACKING DATA ANALYTICS

Cook CCBS 2014

Patient Centered Cancer CareA CULTURE CHANGE: Caregiver teams Paid to Ensure

Cost Effective Patient Health & Satisfaction

*Patient Engagement :disease, health,

preferences, & satisfaction

Comprehensive, *Evidence Based Care Planning& *Coordination

Comprehensive Care Management & *Coordination

Value Based Care:Quality/Cost

and Accessibility

Engineered & EngagedPractice, *IT Supported*Coordinating All Care

Outcomes, *Quality Measure Reporting &*Ongoing

Improvement

Payer Alignment *Affordable & *AccessibleIncentivizing, Sustainable

*MEETS IOM*

High-Quality

Cancer Care GoalsOct 2013 6

Fully Engaged Patient Necessary for Best Outcomes

• Patient’s preferences important in treatment planning

• Patient/family need to actively participate in treatment

management:

– Prompting to report toxicities

– Understanding and compliance to regimen and toxicity

management

– Care coordination and navigation needs: differ by age,

resources, geography, understanding, outside support

• Patient/family need to actively participate in survivorship phase:

follow up, co-morbidities, diet, nutrition, exercise, screening &

prevention

• Patient/family need to actively engage at End of Life

Caregiver Perspective

• Balancing Many Demands

– Patient, Payer, Quality metrics, Billing/Collection,

Funding, Documentation, Value Based Care Needs,

Time Limits

» BUT

• Patient Engagement CRITICAL for Care &

Outcomes

– Engaged Patient necessary for decisions and

compliance to achieve best outcomes

• Patient defined outcomes: cost, toxicity, outcome, and

satisfaction (Family, Friends and Internet also weight in!)

• Payer wants best value: least cost for best health outcome

• TEAM needed: standardized care plans and management

Caregiver Perspective

• Balancing Many Demands

– Patient, Payer, Quality metrics, Billing/Collection, Funding,

Documentation, Value Based Care Needs, Time Limits

»BUT

• Patient Engagement CRITICAL for Care & Outcomes

– Engaged Patient necessary for decisions and compliance to

achieve best outcomes

• Patient defined outcomes: cost, toxicity, outcome, and

satisfaction (Family, Friends and Internet also weight in!)

• Payer wants best value: least cost for best health outcome

• TEAM needed: standardized care plans and management

Clinician and Practices Perspectives

Meaningful

Use1, 2,3

ICD10

Guidelines

Pathways

Plan Pilots

PQRS

Medicare

PQRS

5 Star

Medicare

IOM

Quality

Report

EMR UseCompliance

Audit ThreatsQuality Measures

Limited $$$$$

Expectations

Family/Friends

Knowledge

Clinical Trials

Data vs

Information

Media

Hype

End of LifeEnd of Life

Survivorship

HEALTH

OUTCOMES

Payment Reform For Value: Pilots 2015� Pathway Programs:Pathway Programs:Pathway Programs:Pathway Programs:

− AnthemAnthemAnthemAnthem: Cancer Care Quality Program for Medical Oncology,

2 S Codes if on pathways, 98% Cancer Pathways 2015

− MOASC, So CA; Indiana Oncology Society, IN;

− Blues/Plans: MI, PA, MD

� Oncology Medical Home Pilots:Oncology Medical Home Pilots:Oncology Medical Home Pilots:Oncology Medical Home Pilots:

− Dr. Dr. Dr. Dr. SprandioSprandioSprandioSprandio----DEDEDEDE, COME Home, Dr. McAneny, ABC Pilot Dr.

Bosserman, Innovent-US Oncology, Priority Health, MI

• 12% Cut Cancer Spend: Pathways, Diagnostics, ER/Hospital, EOL

• 2/3 of savings from reducing hospital/ER use (Dr. Sprandio data)

− Medicare: Oncology Care ModelMedicare: Oncology Care ModelMedicare: Oncology Care ModelMedicare: Oncology Care Model, Community Practices, Go live

2016, 1 S code, Pathway payment for MOH work

� United Episodes United Episodes United Episodes United Episodes of Care: 5 sites, 34% savings, 33M Net,

$40,790/patient savings

Payment Reform For Value: Pilots 2015

� California’s IPA/ACO ‘Crash courses and Thoughtful Pilots’

− So. CA Prime Care IPAs with Nearly Full Capitation for Oncology:

• Medical Home Project for Oncology Business

• Wilshire Group MOH work leads IPA to best financial performance

of 12 NAMM/Prime Care IPAs

• Bonus ONLY if group does well with overall at risk costs: drugs, ER,

hospital, ECF, RAF (risk adjusted population payments), all pooled

for bonuses, team work key among doctors, specialists

− No. CA: Hill Physician’ IPAHill Physician’ IPAHill Physician’ IPAHill Physician’ IPA: Large N. CA Group:

• Successful Oncology Successful Oncology Successful Oncology Successful Oncology Case Rate Case Rate Case Rate Case Rate Pilot

−

� Aetna: Step Wise Options: Aetna: Step Wise Options: Aetna: Step Wise Options: Aetna: Step Wise Options: to Pay for move to Value

� ASCOASCOASCOASCO: Payment Reform Work Group : Payment Reform Work Group : Payment Reform Work Group : Payment Reform Work Group Update: 3 Options, complex needs

ANTHEM Cancer Care Quality Program Our model: a Quality Initiative

Confidential & Proprietary

The Cancer Care Quality Program provides

a framework for rewarding high quality cancer care

Oncologists participating in the Cancer Care

Quality Program will receive additional

payment for treatment planning and care

coordination when they select a treatment

regimen that is on Pathway

Web-based platform with decision-support

for Quality Initiative also improves efficiency

of review against Health Plan Medical Policy

and decreases administrative burden for

practices

www.cancercarequalityprogram.com

ANTHEM: Treatment planning payments to support cost-effective care


Enhanced reimbursement for treatment planning and care

coordination will be provided when patient is registered with

the Cancer Care Quality Program and treatment regimen in on

pathway

S0353 reimbursed $350 once at the onset of treatment

S0354 reimbursed $350 no more than monthly while managing

care for an established patient*

S-code billing authorization is triggered through

AIM ProviderPortal when practice selects a regimen that aligns

with WellPoint Cancer Treatment Pathways

Impact of enhanced reimbursement and support for Pathways

Mean practice revenue across regimens

S code reimbursement decreases variation in

revenue across regimens

Without S code $ 3,010 (SD $1,488) With S code $ 3,943


Patient CenteredValue Based Cancer Care

Medical Oncology Home

Quality•Evidence Based

•National quality measures•Validated

•Outcome driven•Care Management

Cost•Access

•Affordability•Cost Effective Pathways•Interval Care Mgmt: •Less ER and Hospital

•EOL Care•Diagnostics

Payer Partnership•Value based payments•Partner with delivery

system•Partner with patient

•Sustainable

Delivery System•Care givers/Caring

•Research•Facilities 24/7 Access

•Pharmaceuticals•Devices

•IT Facilitated•Networked with Providers

16

MOH Population Care Details for PPO and HMO Patients

Plan Type

Patient Categories

ABC PPO

24 Months

Prime Care IV

Total

24 Months

Prime Care IV

Commercial <65

Prime Care IV

Seniors >65

Population

Numbers

Unknown

for PPO

39,451 (Average 24 months)

32,082 7,369 (7000 up to 8000)

Patients Seen 723 1139 395 744

New 146 252 98 154

On Therapy 243 (34%) 280 (25%) 104 (26%) 176(24%)

Chemo-Bio 137 (19%) 182 (16%) 65 (16%) 117 (16%)

Hormone Only 106 (15%) 98 ( 9%) 39 (10%) 59 ( 8%)

Pall/Hospice 10 19 4 15

Died 17(2%) 40 (3.5%) 7 (2%) 33(4%)

On Follow Up 480 859 296 563

17

24 Month

ABC PPO Pts

Care Cost

Details

Care Cost Savings Care Planning Care

Management

Cost: Practice,

IT, MOH care

On Therapy Chemo-Bio -IV: $313,000-Orals: Pending

151 plans 1209 cycles

Hormone -Oral: Pending

Bone Mets $245,000

WBC GF $505,000 <5% to >64% 22% 30/137 1pt St IV WBC GF

Interval Care ER Avoided 3% less 26% ABC 32/137, 23%, (1/3 non cancer)

Hospital 8% less19% less avoidables

30% ABC

26% avoidables

22% InPt 30/137

7% avoidables

10/137

32/137,23%outP

(Half non cancer)

End of Life Rx to death 9.5 weeks

Hospital 30d 20% less 55% ABC 35%, 6/17 Pilot LOS 10:2,2,7,7,8,34

ICU last 30 d 34% less 44% ABC 6% Pilot 1/17

Deaths: Home

vs. Hospital

32% MORE

Hospice/Pal use 27% ABC

65% Pilot 11/17

10/17 Pal/Hosp

Died at home

=59%

Total Savings Benchmarks ABC vs Others

Total Costs ? OnRx + Others $75,500 CP Rx + $725,400 CM Rx+ Calculable

Total Pay Medicare/ABC/ Pilot Estimable Calculable

Oncology Case Rate (OCR)Payment Reform Example

Larry Strieff, MD, Specialty Medical Director, Hematology Oncology Division Chief

Clinical Support, Hill Physicians Medical Group

Hill Physicians Medical Group�Independent Physician Association founded in 1984

�Provider network: 3,800 providers and consultants� 980 Primary Care

� 2,260 Specialists (170 Oncologists)

�Service the Northern California area� 300,000 Members

� 5 Regions - 9 Counties

20

Larry Strieff, MD, CCBS 2014

Methodologies Evaluated21

Mutually

SustainableFFS

FFS & FFS &

Cap

Flat Cap

Rate

Drop to

MC Rates

Drop to

MC Rates Aligned Incentives*Cost

*Quality

*Patient Experience

Cohort

Case Rate


Chronological Cost Pattern for Breast Cancer

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

Pai

d p

er

Cas

e

Months Following Initial Diagnosis

Other Radiology

Radiation Oncology

Medical Oncology

22


Oncology Case Rate (OCR)Bundled Payment System

23

Episode of Care Reimbursement

Cancer Cohorts by Diagnosis

Budget Set Aside for Stop Loss

Removal of Prior Authorization

Quality Management Program

Monthly episodic payment for all oncology-related

services

Cost variation across different cancer types

Ensure fair allocation of risk

Reduce barriers to enable evidence-based cost-

effective care

1. ASCO QOPI Measures

2. Utilization Measures

3. Satisfaction Measures


OCR Cancer Cohorts:Diagnosis Group by Cancer Type

24

Cohort Cancer TypeTotal Unique

Patients, 2010-2014 YTD

1 Colon & Rectum 116

2 Lung 136

3 Breast (female) 287

4 Ovary and other Uterine Adnexa 23

5 Prostate 41

6 Malignant Neoplasm of Other/Unspecified Sites 50

7 Malignant Neoplasm of Lymp/Hema Tissue 169

8 Other Malignant Neoplasm 158

9 Diseases of Blood & Blood-Forming Origin 27

Total Unique Patients 1,007


Trends in Oncology PMPM25


Quality Management Bonus Program�Program encompasses 3 domains

�Clinical measures are subject to audit and chart reviews

�Performance dashboards are shared with oncology groups regularly

26

Clinical Quality Domain

• ~30 QOPI ASCO Clinical Measures

• Subject to Hill review/audit

Satisfaction Domain

• Referring Provider Satisfaction Surveys

• Patient Satisfaction Surveys

Utilization Domain

• Inpatient Bed Days

• Infusion Center Use

• Chemotherapy Initiation

• ED Visits (2014)


Clinical Quality of Care

27

83.0% 82.0%

87.1%

95.9%

60%

70%

80%

90%

100%

2010 2011 2012 2013

ASCO C

linical Q

uality

Perform

ance (30 Q

OPI M

easu

res)

OCR Performance

ASCO = American Society of Clinical Oncology


28


3,177

2,724

2,982

2,889

2,400

2,600

2,800

3,000

3,200

3,400

2012 2013

# I

np

ati

en

t B

ed

Da

ys/

10

00

Me

mb

ers

OCR Non-OCR

OCR Group saved > $1 million

from decreasing bed days


Utilization Measure

29

Inpatient Bed Days

Overall Survival Results30

OCR (N=128) vs. Control (N=146)p = 0.05

All 4 Cancer Cohorts (N=274){Esophageal, Pancreas, Lung, Stomach}

Survival Time (days)Day 0 = first day of chemotherapy

Survival Probability


Summary� OCR practices demonstrated year-over-year improvements in performance on ASCO clinical quality measures.

� OCR practices out-performed standard FFS model in satisfaction and utilization metrics year-over-year.

� OCR practices’ overall survival is non-inferior to the overall survival under a standard FFS model.

� Significant cost savings of greater than $7.5 million in 3.5 years of program experience.

31


Oncology reimbursement reform

is a step-wise process

Vendor Oncology Programs Oncology Medical Homes

Bundles/ Episode Payments

OMH, ACOs, Bundles

Vendor based programs introduce Clinical Pathways

and Measure Adherence along with Quality Measures

More sophisticated

Practices move from vendor based Clinical Pathways programs to Oncology Medical Homes (OMH)

Smaller Practices work with Education Oncology programs such as NJ ION program

Create episode and

bundling methodology test with OMH, as well as deployed in ACO

Provider engagement Index

Low Touch High Touch

Some Clinical

Engagement

OMH deployed in 65% of markets and ACOs by 4Q15

More Clinical

Engagement

High Clinical Engagement

Kolodziej, CCBS 2014

ASCO’s Work to

Improve Payment

for Oncology Practices

CPC Board Update, Dr. Harold Miller 2-15

ASCO’s Efforts to Lower Costs, Increase Value

� Promoting Adherence to Evidence-Based Medicine: ASCO

Guidelines

� Participating in & Promoting “Choosing Wisely”

� Commitment to Quality Improvement: QOPI

� Working with Payers: Integration of Quality Measures into

Reimbursement Decision-Making

� Cultivating a Learning Healthcare System: CancerLinQ

� Establishing Clinically Meaningful Outcomes in Cancer Research

� Payment Reform

� The Value in Cancer Care Task Force

35© 2013-2015 American Society of Clinical Oncology, Center for Healthcare Quality and Payment Reform

DEFICIT

There is Currently No Way to Pay

for Improved Care for Patients

MD/DOSalaries

NursingSalaries

Other Staff Pay

PharmacyOp. Costs

Rent,Utilities,Equip.

E&MCodePmts

InfusionCodePmts

DrugMargin

NOTE: Chart not drawn to scale

$

MD/DOSalaries

NursingSalaries

Other Staff Pay

PharmacyOp. Costs


E&MCodePmts

InfusionCodePmts MD/DO

Salaries

NursingSalaries

Other Staff Pay

PharmacyOp. Costs


E&MCodePmts

InfusionCodePmts

MD/DOSalaries

NursingSalaries

Other Staff Pay

PharmacyOp. Costs


E&MCodePmts

InfusionCodePmts

DrugMargin

DEFICIT

DEFICIT

DrugMargin

DrugMargin

MedicalHomeCosts

DEFICIT

COSTS REVENUE COSTS REVENUE COSTS REVENUE COSTS REVENUE

CURRENTSHIFT TO

GENERIC DRUGSSHIFT TO

ORAL DRUGSIMPROVEDCARE MGT


Current Payments Underpay all Care Phases:New Patient, Infusion, Oral and Survivorship

NOTE: Chart not drawn to scale

$

Timeand

Costs

E&MPmts

COSTS REVENUE

NEW PATIENTTREATMENT MONTH

(INFUSION)TREATMENT MONTH

(ORAL)NON-TREATMENT

MONTH

E&MPmts

COSTS REVENUE

Timeand

Costs

E&MPmts

COSTS REVENUE

Timeand

Costs E&MPmts

COSTS REVENUE

InfusionCodePmts

DrugMargin

Timeand

Costs


New Billing Codes

• New Patient Treatment Planning: This would be a one-time payment for each new patient to cover currently unfunded and underfunded costs related to diagnosis, treatment planning, and patient support prior to the beginning of treatment.

• Monthly Care Coordination and Management: This would be a monthly payment for each patient during the period of time in which treatment is underway and for six months after treatment ends, in order to cover currently unfunded and underfunded costs of patient education, care coordination, and rapid intervention to address complications of treatment.

• Monthly Oral Anti-Cancer Therapy Management: This would be a monthly payment for each patient during months in which they are receiving oral anti-cancer therapy.


Transitioning from Payer-Defined

Rules to ASCO-Defined Rules

Payer-Specific Prior

AuthorizationRequirements

Payer-Specific Prior

AuthorizationRequirements

Payer-SpecificProprietary

Pathway

Payer-SpecificProprietary

Pathway

TODAY

ASCOChoosing

WiselyGuidelinesand QOPI

End of Lifeand

Overuse Measures

ASCO-Developed

or EndorsedPathways

PAYMENT PILOTS FUTURE

An Employer’s View on Cancer Costs

39

Employees with cancer result in more than 33 million

disability days per year.1

Of the 12 million Americans with cancer today, an

estimated 3 million are actively employed.2

Since employer’s cancer medical expenses are increasing faster than general

medical costs, there is no waiting for payment reform – employers are

increasingly taking direct action to manage cancer costs now

Sources:

1. “Cancer Costs Billions Yearly in U.S.” US News and World Report. December 2012.

2. Miller, S. “Employers Focus on Cancer Prevention and Care.” Society for Human Resource Management. November 2013

3. Herr, J. “Employers Becoming More Savvy About Specialty Pharmacy, but Need More Cost Controls.” Midwest Business Group on Health. February 2013.

Specialty oncology drugs currently account for approximately 17%

of the average employer’s total pharmacy spend and are

estimated to rise to 40% by 2020.3

Denise K. Pierce CCBS 2014

Employer Approaches to Managing Cancer Costs

Employer Initiatives

There is a wide variation in approaches, based on company industry, size, and

employee demographics

Claims data warehousing/analysis

Specialty pharmacy benefit

Nurse navigators

Value-based payment design

Oncology medical homes

Solid tumor mapping

• Overall cancer costs/targeting

• “per employee” costs for benefit forecasting

• Case managing the “right treatment for the right patient”

• Integrating adherence measures

• Care coordination beyond the practice doors

• Drug/treatment adherence

• Oncology pathway integration

• Natural narrower networks based on participation

• Learning from current primary care models

• Individualized treatment decision support

Source: DK Pierce & Associates, Inc. DKP Critical Insights®: Employer Cancer Management Evolution Analysis 2014.

Denise K. Pierce CCBS 2014

Oncology Reimbursement Reform MUST:

�BOTH: Reduce costs AND Improve quality

�Develop Sustainable Business models

�Integrate Multimodality Costs: (TCPI Grants)

−Surgical Oncology, Radiation Oncology,

Rehabilitation Services, Transplant, Trials

−Primary Care Coordination

−Better Patient Engagement

�IMPROVE OVERALL HEALTH OUTCOMES

Kolodziej, CCBS 2014

Four Revolutions in Oncology

Cancer

Panomics Big data

Payment

reform/ValuePatient

engagement

Lichter OBS 2014

ASCO Responds: Cancer LINQ: Learning Intelligence Network for Quality

Lichter OBS 2014

#4 Pan Omics• Diagnostic Testing

– Molecular analytics at diagnosis

• Treatment pairing

• Prognosis

• Prevention

– Molecular analysis of metastasis/recurrences

• Treatment stratifications

• Clinical Trial specifity

• Genomics, Proteomics, Metabolomics

• Challenge of Test, Interpretation, Meaning

Value Based Care Transition• Re-Engineering of

– Clinician Roles, Processes, IT and Data collection

• Team based care, continuous support for patients

• Minimize ER, Hospital and futile therapies

• Maximize trials and targeted care with high value

• IT facilitated data collection and analytics support rapid

improvements in larger systems of care

– Patient engaged, educated regarding values and

preferences with more informative tools

– Payer relationships: support value based care

• Cost + margin based on outcomes and quality measures

engaging physicians &patients in cost effective, high ...md... · patient centered value based...

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