Navigating The Oncology Care Maze

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Navigating The Oncology Care Maze

  1. 1. Navigating The Oncology Care Maze: Evidence Based Medicine As A Pathway For Payers, Providers & Patients The Center For Business Intelligence 3rd Annual Effective Oncology Benefit Management Conference October 6, 2008 Dr. Mickey Goldsmith Chief Medical Officer, New Century Infusion Solutions
  2. 2. Why I’m Facilitating This Workshop I have a broad perspective on oncology care: • Practicing community oncologist 25+ years • Managed care executive & medical group CEO – City of Hope Oncology Network • Single specialty IPA with 800,000 lives • Speaker on oncology managed care issues 2
  3. 3. Why I’m Facilitating This Workshop – Currently Medical Director of New Century Infusion Solutions (NCIS) – NCIS is the first Integrated Single Specialty Provider (ISSP) in oncology – A new type of health care payer » Takes risk » Capitated (professional, drugs & radiation therapy) » “Payer for the payers” – Share NCIS experience • Policies developed from EBM can cost effectively deliver oncology care • Specific takeaway ideas other payers can use 3
  4. 4. Workshop Agenda • The Oncology Landscape – Current perspectives – A new perspective • Evidence Based Medicine – What it is, & what it is not • EBM in Community Oncology Care – 5 specific examples • Case Study Exercise 4
  5. 5. The Oncology Care Landscape Current Perspective Payers • Challenges – Supporting Cost-effective Cancer Care – Controlling Rapidly Escalating Rx Costs – Managing Off-label Rx Use 5
  6. 6. The Oncology Care Landscape Current Perspective Providers • Challenges – Incorporating Evolving Standards of Care Into Practice – Receiving Adequate Reimbursement – Utilizing New Agents and Therapies 6
  7. 7. The Oncology Care Landscape Current Perspective Patients • Challenges – Working with payers and providers to access appropriate care in a timely manner – Receiving high quality cancer care 7
  8. 8. The Oncology Care Landscape Current Perspective Patient Need for Quality Care New Research Provider Off-Label Fees Rx New Agents Rx Costs Delivery of Cost Effective Oncology Care 8
  9. 9. Changing the Oncology Care Landscape There’s a need for a new type of oncology care system to handle the financial and clinical challenges of care from all perspectives: •Financial challenges – Some heath care plans can’t manage risk or are unwilling to bear all of the risk – ASP +6 reimbursement poses serious practice sustainability challenges for many providers – Acceptance by provider of drug replacement & “brown bag” issues 9
  10. 10. Changing the Oncology Care Landscape There’s a need for a new type of oncology care system to handle the financial and clinical challenges of care from all perspectives (continued): •Clinical – Many community oncologists have difficulty keeping up on alternative treatments and advances in the standard of care published in the literature – Payers need to know which treatments are appropriate 10
  11. 11. The New Oncology Care Landscape Leveraging the power of EBM can change the landscape to: Payer Prior Information Authorization Technology Provider Provider New Network Professional Agents Fees Patient Provider Site of Rx Off-Label Rx Preferred Fees Administration Drug List Delivery of Cost Effective Oncology Care Patient-Centered EBM Care & Guaranteed Payer Savings 11
  12. 12. The New Oncology Care Landscape • New Century Infusion Solutions – Overcomes key payer challenges • Cost escalation • Over & under utilization – Solves key provider challenges • Responsive prior authorization policies and processes • Appropriate and timely reimbursement 12
  13. 13. The New Oncology Care Landscape • New Century Infusion Solutions resolves the financial and clinical challenges of cancer care – Financial • Assumes the risk • Acts as the “payer for the payer” • Facilitates delivery of appropriate care by eliminating reimbursement misalignment between payers, providers and pharmacy – Clinical • Uses EBM as a patient-centric pathway to deliver full spectrum oncology care • EBM optimizes curative, adjuvant and palliative therapies 13
  14. 14. Evidence Based Medicine The fact that an opinion has been widely held is no evidence whatever that it is not utterly absurd… -Bertrand Russell, philosopher, historian, logician 14
  15. 15. Evidence Based Medicine Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. - The Cochrane Collaboration 15
  16. 16. Evidence Based Medicine (EBM) What it is What it is not • Based on Research • Uniformly practiced by • Dependent on quality of clinicians evidence • Based on a consensus • Rapidly evolving definition of • Outcomes oriented “effectiveness” • Guidelines based • Fully integrated into • Decision oriented oncology care delivery systems • Directly tied to payer return on investment
  17. 17. EBM in Community Oncology Care • Using EBM to advance the standard of care in a community oncology setting blends: ASCO Research Patient Payer Dx & Rx Therapy Authorization NCCN Process Evidence driven, Curative consensus based guidelines Adjuvant Palliative Patient CMS Progress Determinations 17
  18. 18. EBM in Community Oncology Care Leveraging the power of EBM 1. Develop well defined policies based on recognized protocols 2. Distinguish between accepted and acceptable treatment protocols 3. Integrate oncology specialists into the authorization process 4. Orient the Payer Rx authorization process to say “yes” 5. Embrace advance care planning as an integral part of the spectrum of patient care 18
  19. 19. Leveraging the power of EBM 1. Develop well defined policies based on recognized protocols Situation • Not all cancers have standard protocols • 40% of Rx is off-label use Opportunity • Develop policies based on peer-reviewed literature, for example: – Prophylaxis of CINV based on emetogenic potential of chemotherapy agents – Erythropoiesis-Stimulating Agents (ESA) 19
  20. 20. Leveraging the power of EBM 2. Distinguish between accepted and acceptable treatment protocols Situation • Erythropoiesis-Stimulating Agents (ESA) • Some health plans only authorize FDA approved package insert dosing schedules Opportunity • There are many acceptable alternative regimens • Facilitate provider preference 20
  21. 21. Leveraging the power of EBM 3. Integrate oncology specialists into the authorization process Situation • 40% of Rx utilization in community oncology is off-label use • EBM guidelines and standards of care are rapidly evolving • Most community oncologists don’t have the opportunity to speak directly with a peer when navigating the payer’s authorization process Opportunity • Have oncologists with oncology practice experience and knowledge of cutting edge EBM involved in the first line authorization review to accelerate P.A. resolution and patient treatment 21
  22. 22. Leveraging the power of EBM 4 Key Steps to integrating oncology specialists into the authorization process: 1. Oncologist as initial reviewer – Compliance • Health plan • National oncology guidelines – Regimen • Therapy appropriate to disease staging • Treatment length 2. Oncologist & oncology pharmacist collaboration – Preferred drug list – Dosage appropriate to patient height and weight – Dose optimization to prevent wastage and to promote cost effectiveness 3. Inclusion of a 2nd community oncologist as a 2nd level review prior to any recommendation for an authorization denial 4. 3rd level academically based reviewer is available at health plan’s request 22
  23. 23. Leveraging the power of EBM 4. Orient the Payer Rx authorization process to say “yes” to appropriate care Situation • Most Rx authorization gatekeeper processes are designed to save money by saying “no” Opportunity • Standards of care vary by practice – Authorization process facilitates advancing SOC • “Please educate me” • Leverage technology to provide empowering information – Internet based systems – Authorization processing information • Diagnosis & staging • Regimen info & patient history • J-Codes • EBM Literature references 23
  24. 24. Leveraging the power of EBM Benefits From Orienting the Payer Rx Authorization Process to Say “Yes” to Appropriate Care • Appropriate Patient Care – NCIS experience: 1 denial in 2 years • Wrong drug for stage of disease • Denial upheld by health plan
  25. 25. Leveraging the power of EBM 5. Embrace advance care planning as an integral part of the spectrum of patient care Situation • End of life care is one of the most costly stages of oncology care Opportunity • Do the right thing • Incorporate EBM end of life guidelines into oncology practice • Reimburse providers for appropriate: – Palliative Rx – Encounters: office/hospice/home 25
  26. 26. Thank You 26
  27. 27. About The Facilitator • Dr. Myron “Mickey” Goldsmith is the Chief Medical Officer for New Century Infusion Solutions (NCIS). NCIS is the first and only Integrated Single Specialty Provider delivering full-spectrum solutions in the oncology care market. • A community based medical oncologist with over 25 years experience, Dr. Goldsmith, has: – Served as Executive Director of Development for the City of Hope Oncology Network – Consulted to many health plan, disease management and pharmaceutical clients – Authored many articles concerning clinical research in hematology or oncology and several publications on issues of oncology managed care. • Dr. Goldsmith was a graduate of Temple University and Temple Medical School and performed his postgraduate training at the Graduate Hospital of the University of Pennsylvania. He can be reached at mgoldsmithmd@newcenturyinfusionsolutions.com 27

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