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Transitioning to Value Based Care: Tennessee Oncology, A Case Study

Tennessee Oncology, a large community oncology practice, faces significant market pressures and is transitioning to a value-based care model to improve outcomes and reduce costs. Key strategies include expanding patient-centered medical homes, integrating clinical pathways, and negotiating new payment systems to align costs with revenue. The initiative aims to enhance patient care, control unnecessary treatments, and adapt to evolving healthcare policies while facing challenges from dominant local payers and competition.

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Transitioning to Value Based Care: Tennessee Oncology A Case Study Presentation to Norris Cotton Cancer Center Grand Rounds October 7, 2014 Wes Chapman
Disclosure Statement • I do not have any financial interests. • I do not intend to discuss off-label or investigational use(s) of a product or device. • I attest that I am not receiving direct payments from a commercial entity with respect to this activity.
“Oncologists should become value-based providers by eliminating unnecessary tests, prescribing cheaper alternatives when therapeutic equivalents exist, and keep calling for payment reform” Ezekiel J. Emanuel, MD, PhD ASCO Annual meeting, 2014
Tennessee Oncology at a Glance • Community oncology “mega-practice” – 85 physicians, 25+ locations, 40+% state market share, 70+% market share in service area • Nashville based – 3 hospital system market – HCA, Ascension affiliate (St. Thomas), Vanderbilt • Long-standing referral relationships with HCA & Ascension • Very large clinical trial presence through Sarah Cannon (SCRI) – 2nd largest Phase 1 unit in US • QOPI certified, Aria (Varian) EMR in all practices, standardized billing through GE Centricity • Participates in Mission Point ACO via St. Thomas
Getting to Know TN Oncology Embattled Self Image
A Self Image Founded in Harsh Reality
7 MARKET PRESSURE ON COMMUNITY ONCOLOGISTS • Over last six years – 331 clinics closed – 600 merged or acquired – hospital acquisitions/agreements due to huge margin advantage: • Site of service differentials for hospitals is huge revenue advantage • 340B pricing gives non-profit facilities huge cost advantage * Community Oncology Alliance Report. April 2014.
Exacerbating the Cost Growth in Cancer Care
Cost Drivers Wreaking Budgetary Havoc
10 NOTALL CHANGES ARE ADVERSE THREE CRITICAL POLICY SHIFTS ARE UNDERWAY 1. Reference pricing – elimination of site of service differentials approved by CMS * 2. 340B seems to be under scrutiny for reduction – opposition from pharma, private providers, payers 3. CMS is expanding favorable program development: 1. COME HOME medical home project 2. End of life palliation program via CMMI 3. Solicitation of opinion for Value Based Care Models in Medical Oncology * Obama administration okays reference pricing. FierceHealthFinance. May 18, 2014. * Insurers Push to Reign in Spending on Cancer Care.Wall Street Journal. May 27, 2014.
Adapting to a Changing Environment
A Brief Review of Our View of Value Based Care Source: Aetna Inc.
VALUE-BASED CARE HAS ARRIVED IN ONCOLOGY 13 Inherent variation Special cause variation PQRS, MU, V-b purchasing EMR Pathway technology Risk stratification tools Patient triage services
14 VALUE-BASED CARE HAS ARRIVED IN ONCOLOGY Inherent variation Special cause variation - Generic vs. branded drug utilization - bundles Cost management technology Utilization management services Private oncology ACOs, Payer sponsored bundles
15 OUR FOCUS - COMMERCIAL HEALTH PLANS PROBLEMS Commercial health plans are paying too much (cost) and receiving too little (value). 1. Regimens – controlled by MD 2. Formulary – controlled by FDA, and practice 3. Utilization management solutions – controlled by third parties 4. Patient management – Typically not delivered 5. Transparency – No plans, no audits
16 PAYER SELF IMAGE – PAINFUL LOSS OF CONTROL 1. Reporting requirements without control • Publicly transparent quality scores (NCQUA HEDIS scores) 2. Provider reluctance to adopt: A. Payment for value models B. Payment for savings models C. ACOs 3. Oncologists “control hearts & minds” 4. No auditability of pathways, bundled payments or otherwise
TN Oncology Incentives to Value Based Care
ALIGNED CONCEPTS OF VALUE PAYER – PROVIDER – PATIENT GOAL ALIGNMENT 18 Cost Reduction FFS Pathway attribution Bundles Quality Improvement PCMH
EVOLUTION OF VALUE BASED CARE MODELS 19 Bundles PCMH ACOs -Only requires pathway adherence -Possibly single sign-on sans pre-auth Robs pharma revenue -Systematic triage -Patient Education -Palliation Robs hospital revenue Requires tech integration/APIs & provider cooperation Requires hospital partnership
The Imperative – Match Costs with Revenue TODAY
MULTIPLE INDUSTRY-WIDE VALUE-BASED CARE REQUIREMENTS ARE HERE… 21 • Commercial payer programs are also growing: • National plans: WellPoint, Aetna, Cigna • Regional plans: Regence BCBS, Highmark BCBS, BCBS TN
Strategic Framework for Change (SWOT) • Historical Strengths: • Offering first rate cancer care and access to clinical trials • Ability to know and support patients needs at the community level • Access to economies in purchasing, contracting and billing • Tremendous referral base with dedicated hospital partners • Investment in Best-in-Class systems • Appealing venue and practice for physician recruitment • Capability to rapidly implement new products and services to respond to market changes/opportunities • Low cost provider – operates under Vanderbilt price umbrella • Weaknesses: • TN market dominated by local BCBS – limited bandwidth for payment reform • CON state limiting expansion in certain related service lines – radiation therapy • Locally dominant market share limits “in-market” growth • Limited history of standard care practices across clinical sites
Strategic Framework for Change (SWOT) • Opportunities: – Implement Medical Home – position for future payment reform, control costs, standardize practice – Aggressive movement to expand economies of scale through related GPO – New service lines, e.g. genetics lab – Expand data use for improved care delivery – particularly pathways – Numerous payment reform projects available through private payers and CMC/CMMI • Threats: – Ongoing Medicare fiscal woes and threat of very high priced new oncology drugs – Ongoing 340 B and site of service advantage to local competition – Ongoing drug shortages – Locally dominant payer slow to move into Value Based reimbursement – Payers moving to proprietary pathways systems – dramatically complicating care delivery and billing
Changes to Survive/Thrive • Done: Service Line Expansion – Expanded Laboratory capability – Specialty pharmacy for orals – Led formation of Nationwide Oncology GPO (RainTree Oncology) 50+ practices, 500+ MDs – Genetics Laboratory (Pending) – Continued geographic growth (Chattanooga) • Consider: Aggressive move to Oncology Patient Centered Medical Home via NCQA accreditation as PCSP – Adoption of Clinical Pathways – Incorporation of Care Plans into practice, patient, referrals – Development of Triage/Patient Management System – Dramatic expansion of palliative care program including CMMI Grant • Required with Medical Home: Negotiate changed payment systems with Payers based on ACO or bundles model – if you can’t do this, you will go broke!
Consideration: Do Oncology PCMHs Actually Improve Care or Reduce Costs? Evidence & Expert Opinion • Costs Savings - Evidence – Multi-year, 5 site study through UnitedHealthcare (1): • All sites PCMHs (3 were members of COME HOME project & RainTree) • Sites paid a fixed fee per patient – no mark-up on drugs • Savings based on total cost of care – breast , colon & lung cancer • Savings of 34% of expected costs ($34 million) • Savings from hospitalizations and therapeutic radiology – Movement to Pathways systems seems to offer 15% savings on Drugs year 1, 6% additional year 2. (2) – Come Home savings of $33.5 million based over 3 years and 7 practices – (percentage not given) (3)
Consideration: Do Oncology PCMHs Actually Improve Care or Reduce Costs? Evidence • Quality – Evidence Positive for Oncology Medical Homes – Reported Practice Results (4): • ED visits reduced 68% • Hospital Admissions reduced 51% • Avg. LOS reduced 21% • Out Patient visits cut by 22% for all hematology & oncology • Savings of $11,955 per chemotherapy patient • Quality – Mixed Reviews – Particularly Primary Care – “Despite widespread enthusiasm for the medical home concept, few peer-reviewed publications have found that transforming primary care practices into medical homes (as defined by common recognition tools and in typical practice settings) produces measurable improvements in the quality and efficiency of care.” (5)
Consideration: Do Oncology PCMHs Actually Improve Care or Reduce Costs? Quality Evidence
RESULTS OF UNITED HEALTHCARE PAYMENT REFORM PROJECT 28 3 years, 5 sites, 810 Patients, PCMHs Result: Predicted FFS cost = $98M Actual cost = $64M % savings = 34% “There was no difference between the groups on multiple quality measures.” Conclusion: “Modifying the current fee-for-service payment system for cancer therapy with feedback data and financial incentives that reward outcomes and cost efficiency resulted in a significant total cost reduction.” Newcomer LN. Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model. Doi:10.1200/JOP.2014.001488
UNITED HEALTHCARE COMPENSATION MODEL “Medical oncologists were paid a single fee, in lieu of any drug margin, to treat their patients. Chemotherapy medications were reimbursed at the average sales price, a proxy for actual cost.” 29
Our Conclusions Regarding Oncology PCMH • PCMHs seem to work quite well in reducing process variation through the use of Pathways – Pathways also can reduce drug costs from process variation – but this is a year 1 & 2 opportunity • PCMHs seem to work quite well in reducing total costs through management of unnecessary hospital admissions and ED use – This is an obvious benefit to the patient – providing the right care, on time and in the right venue • Palliation offered through the PCMH is simply better for the patient and better quality • It is unclear which clinical outcomes measures are impacted by oncology PCMHs
Medical Home Deliverable Care Considerations  Cancer care that is:  Coordinated with the central focus on the patient and their entire medical condition  Optimized based on evidence-based medicine to produce quality outcomes  Accessible and efficient, with treatment provided in the highest quality, lowest cost setting for the patient  Delivered in a patient-centric, caring environment that optimizes patient satisfaction  Continuously improved by measuring and benchmarking results against other facilities providing care so that best practices “raise the bar” in delivering care Institute of Medicine (IOM) report in 1999, Ensuring Quality Cancer Care
Oncology Medical Home – Design Considerations -We Match up Pretty Well • Standardized evidence-based guidelines for prevention, diagnosis, treatment, and palliative care - Pathways • Measurement and continuous monitoring of a core set of quality measures – NCQA PCSP Model • Agreed upon care plan prepared by experienced professionals, outlining the goals of care – Care Plans • Access to clinical trials - SCRI • Policies to ensure full disclosure to patients of information about appropriate treatment options – Care Plans, PCSP • Mechanisms to coordinate services – Patient Management • Quality care at the end of life - Palliation • Policies to address the barriers to receiving appropriate cancer care in specific segments of the population – PCSP, Internal Policies Institute of Medicine (IOM) report in 1999, Ensuring Quality Cancer Care
Medical Home Accreditation
Other Programs Evaluated in Our Planning Source: The Advisory Board
Sites of Focused Study • Consultants in Medical Oncology and Hematology, Drexel PA – Level 3 PCSP, led by Dr. John Sprandio – Pioneers in Oncology Medical Home, constant focus on patient engagement and best practice adherence – Proprietary EMR and patient management software – Focused first on Triage, then pro-active patient management – Self Funded Medical Home Development • New Mexico Cancer Center – CoC certified, led by Dr. Barbara L. McAneny – Founder of COME HOME Project, $19.8 million CMMI Grant – Includes 7 practices, and proprietary Pathways and Patient Management software
Consultants in Medical Oncology and Hematology: Summary Facts
Consultants in Medical Oncology and Hematology: Methods
New Mexico Cancer Center & COME HOME
New Mexico Cancer Center & COME HOME - Methods • Practice Size 10-15 providers – 7 practices • Large emphasis on IP/IT development • Special emphasis on Triage – with proprietary system • Includes Saturday clinic and “after hours” • Multiple layers of patient support • Some practices focused on patient acuity scoring
Our Distillation: 4 Pillars of our Medical Home • Pathways: NCCN compliant Pathways are the base level requirement for our PCMH, Rx, Genetics and Diagnostic imaging – Have to be: • Rigorously and systematically maintained • Independent of any payer organization • Cloud based • Linked to our Aria EMR • Capable of practice level customization • Capable of producing supportive care pathways as well • Capable of easily dealing with our clinical trial volume • Capable of producing Care Plans – Key metrics: 90% Attribution, 80% Compliance
Pathway System Selection Process • All Major commercial systems evaluated – Via Oncology: Not payer or GPO affiliated, excellent clinical content & systems, good patient materials & palliation – P4: Associated with Cardinal and various payer organizations, good clinical content, limited integration with our system – Eviti: Multiple payer customers nationwide, Express Scripts, limited system integration – Clear Value Plus: McKesson product, excellent integration, NCCN affiliation, strong competitor – Flat Iron: Juvenile stage pathway product, Altos EMR tie in, takes all practice data for sale to pharma Via and Clear Value were our 1&2 –We went with Via
Impact of Pathways on Compliance Aetna Study
Current Pathway Utilization
Via Oncology System - Interface
Via Oncology System - Interface
Care Plans • Care plans: A documented account of care shared with the Patient, Payer and other Providers at transition of care. Form a fundamental information tool with: – Payers: • Care plans form the basis for attribution and compliance metrics • All payer expectations are driven by care plans and subsequent reports/audits • Flexibility in plan design important – Patients: • Plans for the fundamental curriculum around which patient education takes place • Plans form the basis for subsequent patient management – Referrals: • Plans are the fundamental information tool for MU compliance • Plans facilitate continuity of care • Key Metric: Shared with the Patient, Payer and other Providers at 90% of transitions of care, includes all care provided by the practice and additional elements as mandated by Meaningful Use.
Pathway System Addresses Phase 1 Care Plan Requirement
Patient Management • Reactive (triage) and proactive management of disease between office visits; systematic response to patient concerns, including non-oncology. Goals: Improved patient care; improved outcomes; reduced cost; increased adherence to care plans. Compliance • Key considerations: – Must offer triage first, then proactive patient management – Must integrate with phone and data management systems – Triage must conform with best practices, and integrate smoothly with scheduling – Must include multi-modal including phone, text, email – Must support development of supportive care pathways with automatic notifications and work lists – Must integrate with Pharmacy • This is a team sport – must include all members of the care team • Key Metric: Control 90% of ED and hospital use
Patient Management - System Use Cases • Provider – Triage: Safe, timely intuitive triage – Patient management: Supportive care based on predictive pathways – Risk analysis based on clinical data – Frequent periodic patient status/distress reporting • Payer – Timely reports on: triage, status variation, pathway adjustment • Patient – Meaningful and timely educational materials – Direct access to supportive care – Meaningful information regarding status
Triage/Engagement Considerations Telephonic Triage is a requirement for “Stage 1” Medical Home Development Triage Has three fundamental components  1) Patient engagement and symptom/situation description  2) Tier the patients condition based on objective criteria, reflecting symptoms, history and risk  3) Direct the patient to the most appropriate medical care Triage frequently means late stage correction of a problem - anticipation, training, education should eliminate most triage Triage system needs to be built to accommodate:  1) Broader patient engagement requirements – e.g. status reporting  2) Prospective tiering and planning based on treatment and status  3) Demographic data inputs from EMR
Validated Tools Edmonton Symptom Assessment System: Edmonton Zone Palliative Care Program: http://www.palliative.org/tools.html
Validated Tools Ontario Cancer Symptom Management: https://smg.cancercare.on.ca/
Validated Tools Telephone Triage Protocols for Nurses, Briggs: This is the standard reference in the US. Ideally, we would be able to include in an electronic format.  3 Tier Protocols  Not Optimized to Cancer  Consulting support seems available via Ms. Briggs Emergency Nursing 5-Tier Triage Protocols (also by Ms. Briggs)  Optimized for emergency use  Probably more complicated than needed Telephone Triage for Oncology Nurses, Hickey & Newton:  Optimized for Oncology  Triage protocols are a mix of oncology and other  Needs consistency and standardization
System Design & Considerations  System built on hosted cloud platform – must be HIPAA compliant  Built around relational data base – tables built from validated sources  Tiering and work-listing for call return & patient response  Maintains and reports real-time on functionality data for system  Integrates with and captures phone system data  Role & Permission based for access and input  Receives ADT feeds for demographic information from demographic master system  Uses standardized and validated patient symptom ranking and distress scoring  Build done in iterative phases:  First – Triage  Second – Patient status reporting (used for outcomes, risk, standardized check-in)  Third – Patient risk/acuity scoring with work-listed outreach requirements  Fourth – Incoming partner data feeds & Date Warehouse  Fifth – Learning system: first focused on actual vs expected, “gamified” to patient
Patient Management – Predictive Analytics • Initial Objective – Risk for Hospitalization • Key design consideration – based on clinical (EMR) rather than payer data • Must be based on experience in medical oncology – general system not relevant for our needs • Depends on data partnerships with referral hospitals • Evaluated 15-20 systems • Chose Clinicast – group spun out of Kaiser
Palliation • Integral part of patient management – we use for all patients (certain clinics), beginning with the first visit • Difficult to justify at the practice level outside of Value Based Care payment model • Moving to patient resources from the pathways system • Really depends on good patient management tools • We applied to participate in the CMMI new palliation model with a local hospice
57 THE FOUR FUNDAMENTALS OF A VALUE-BASED CANCER SOLUTION 4. Palliation -- always relevant throughout the patient’s course of treatment • Alive Hospice / Tennessee Oncology Partnership • Applied for Medicare Care Choices grant, allows for simultaneous curative and palliative care by a non-profit hospice • Pain management • Establishment of patient-driven treatment goals
58 IN-PATIENT CONTINUES TO DOMINATE EOL COSTS Mean OP chemo cost Mean OP service cost Mean hospice cost Mean IP cost $7,834 $9,230 $10,051 $10,362 $11,469 $25,261 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 6th MBD 5th MBD 4th MBD 3rd MBD 2nd MBD Last MBD Commercial Patients, Mean $/month N = 28,530
IT System Before Value Based Care
IT System After Value Based Care
The Alternative to Physician Directed Value Based Care – Aggressive Expansion by PA Companies PA Company Planning documents
The Alternative to Physician Directed Value Based Care – Aggressive Expansion by PA Companies PA Company Planning documents
The Alternative to Physician Directed Value Based Care – Aggressive Expansion by PA Companies PA Company Planning documents
VALUE-BASED PERFORMANCE SUMMARY OF KEY CONCEPTS AT TENNESSEE ONCOLOGY  Best care practices  transparency, adherence, and auditability  Patient-Centered Care = Value Delivery Communication of expected outcomes and risks  Communication of costs to patient Empower patients and families to make informed choices  Respect of patients’ decisions and resources  Value delivery achieved through a certified patient-centered medical home  4 pillars: (1) Pathways; (2) Care plans; (3) Patient management; (4) Palliation 64
Citations 1. Newcomer LN et al: Changing Physician Incentives: An Episode Payment Model. JOP.ASCO. July 14,2014, Published ahead of Print. 2. Feinberg B et al. Third-Party Validation of Observed Savings From an Oncology Pathways Program. American Journal of Managed Care. Volume 19, Special Issue 4. May/June 2013 3. Oncology Business News, August 2014 4. DOI: 10.1200/jop.2014.001386; published ahead of print at jop.ascopubs.org on March 11,2014. 5. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care. JAMA. 2014;311(8):815-825. doi:10.1001/jama.2014.353.

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Transitioning to Value Based Care: Tennessee Oncology, A Case Study

  • 1.
    Transitioning to ValueBased Care: Tennessee Oncology A Case Study Presentation to Norris Cotton Cancer Center Grand Rounds October 7, 2014 Wes Chapman
  • 2.
    Disclosure Statement •I do not have any financial interests. • I do not intend to discuss off-label or investigational use(s) of a product or device. • I attest that I am not receiving direct payments from a commercial entity with respect to this activity.
  • 3.
    “Oncologists should becomevalue-based providers by eliminating unnecessary tests, prescribing cheaper alternatives when therapeutic equivalents exist, and keep calling for payment reform” Ezekiel J. Emanuel, MD, PhD ASCO Annual meeting, 2014
  • 4.
    Tennessee Oncology ata Glance • Community oncology “mega-practice” – 85 physicians, 25+ locations, 40+% state market share, 70+% market share in service area • Nashville based – 3 hospital system market – HCA, Ascension affiliate (St. Thomas), Vanderbilt • Long-standing referral relationships with HCA & Ascension • Very large clinical trial presence through Sarah Cannon (SCRI) – 2nd largest Phase 1 unit in US • QOPI certified, Aria (Varian) EMR in all practices, standardized billing through GE Centricity • Participates in Mission Point ACO via St. Thomas
  • 5.
    Getting to KnowTN Oncology Embattled Self Image
  • 6.
    A Self ImageFounded in Harsh Reality
  • 7.
    7 MARKET PRESSUREON COMMUNITY ONCOLOGISTS • Over last six years – 331 clinics closed – 600 merged or acquired – hospital acquisitions/agreements due to huge margin advantage: • Site of service differentials for hospitals is huge revenue advantage • 340B pricing gives non-profit facilities huge cost advantage * Community Oncology Alliance Report. April 2014.
  • 8.
    Exacerbating the CostGrowth in Cancer Care
  • 9.
    Cost Drivers WreakingBudgetary Havoc
  • 10.
    10 NOTALL CHANGESARE ADVERSE THREE CRITICAL POLICY SHIFTS ARE UNDERWAY 1. Reference pricing – elimination of site of service differentials approved by CMS * 2. 340B seems to be under scrutiny for reduction – opposition from pharma, private providers, payers 3. CMS is expanding favorable program development: 1. COME HOME medical home project 2. End of life palliation program via CMMI 3. Solicitation of opinion for Value Based Care Models in Medical Oncology * Obama administration okays reference pricing. FierceHealthFinance. May 18, 2014. * Insurers Push to Reign in Spending on Cancer Care.Wall Street Journal. May 27, 2014.
  • 11.
    Adapting to aChanging Environment
  • 12.
    A Brief Reviewof Our View of Value Based Care Source: Aetna Inc.
  • 13.
    VALUE-BASED CARE HASARRIVED IN ONCOLOGY 13 Inherent variation Special cause variation PQRS, MU, V-b purchasing EMR Pathway technology Risk stratification tools Patient triage services
  • 14.
    14 VALUE-BASED CAREHAS ARRIVED IN ONCOLOGY Inherent variation Special cause variation - Generic vs. branded drug utilization - bundles Cost management technology Utilization management services Private oncology ACOs, Payer sponsored bundles
  • 15.
    15 OUR FOCUS- COMMERCIAL HEALTH PLANS PROBLEMS Commercial health plans are paying too much (cost) and receiving too little (value). 1. Regimens – controlled by MD 2. Formulary – controlled by FDA, and practice 3. Utilization management solutions – controlled by third parties 4. Patient management – Typically not delivered 5. Transparency – No plans, no audits
  • 16.
    16 PAYER SELFIMAGE – PAINFUL LOSS OF CONTROL 1. Reporting requirements without control • Publicly transparent quality scores (NCQUA HEDIS scores) 2. Provider reluctance to adopt: A. Payment for value models B. Payment for savings models C. ACOs 3. Oncologists “control hearts & minds” 4. No auditability of pathways, bundled payments or otherwise
  • 17.
    TN Oncology Incentivesto Value Based Care
  • 18.
    ALIGNED CONCEPTS OFVALUE PAYER – PROVIDER – PATIENT GOAL ALIGNMENT 18 Cost Reduction FFS Pathway attribution Bundles Quality Improvement PCMH
  • 19.
    EVOLUTION OF VALUEBASED CARE MODELS 19 Bundles PCMH ACOs -Only requires pathway adherence -Possibly single sign-on sans pre-auth Robs pharma revenue -Systematic triage -Patient Education -Palliation Robs hospital revenue Requires tech integration/APIs & provider cooperation Requires hospital partnership
  • 20.
    The Imperative –Match Costs with Revenue TODAY
  • 21.
    MULTIPLE INDUSTRY-WIDE VALUE-BASED CARE REQUIREMENTS ARE HERE… 21 • Commercial payer programs are also growing: • National plans: WellPoint, Aetna, Cigna • Regional plans: Regence BCBS, Highmark BCBS, BCBS TN
  • 22.
    Strategic Framework forChange (SWOT) • Historical Strengths: • Offering first rate cancer care and access to clinical trials • Ability to know and support patients needs at the community level • Access to economies in purchasing, contracting and billing • Tremendous referral base with dedicated hospital partners • Investment in Best-in-Class systems • Appealing venue and practice for physician recruitment • Capability to rapidly implement new products and services to respond to market changes/opportunities • Low cost provider – operates under Vanderbilt price umbrella • Weaknesses: • TN market dominated by local BCBS – limited bandwidth for payment reform • CON state limiting expansion in certain related service lines – radiation therapy • Locally dominant market share limits “in-market” growth • Limited history of standard care practices across clinical sites
  • 23.
    Strategic Framework forChange (SWOT) • Opportunities: – Implement Medical Home – position for future payment reform, control costs, standardize practice – Aggressive movement to expand economies of scale through related GPO – New service lines, e.g. genetics lab – Expand data use for improved care delivery – particularly pathways – Numerous payment reform projects available through private payers and CMC/CMMI • Threats: – Ongoing Medicare fiscal woes and threat of very high priced new oncology drugs – Ongoing 340 B and site of service advantage to local competition – Ongoing drug shortages – Locally dominant payer slow to move into Value Based reimbursement – Payers moving to proprietary pathways systems – dramatically complicating care delivery and billing
  • 24.
    Changes to Survive/Thrive • Done: Service Line Expansion – Expanded Laboratory capability – Specialty pharmacy for orals – Led formation of Nationwide Oncology GPO (RainTree Oncology) 50+ practices, 500+ MDs – Genetics Laboratory (Pending) – Continued geographic growth (Chattanooga) • Consider: Aggressive move to Oncology Patient Centered Medical Home via NCQA accreditation as PCSP – Adoption of Clinical Pathways – Incorporation of Care Plans into practice, patient, referrals – Development of Triage/Patient Management System – Dramatic expansion of palliative care program including CMMI Grant • Required with Medical Home: Negotiate changed payment systems with Payers based on ACO or bundles model – if you can’t do this, you will go broke!
  • 25.
    Consideration: Do OncologyPCMHs Actually Improve Care or Reduce Costs? Evidence & Expert Opinion • Costs Savings - Evidence – Multi-year, 5 site study through UnitedHealthcare (1): • All sites PCMHs (3 were members of COME HOME project & RainTree) • Sites paid a fixed fee per patient – no mark-up on drugs • Savings based on total cost of care – breast , colon & lung cancer • Savings of 34% of expected costs ($34 million) • Savings from hospitalizations and therapeutic radiology – Movement to Pathways systems seems to offer 15% savings on Drugs year 1, 6% additional year 2. (2) – Come Home savings of $33.5 million based over 3 years and 7 practices – (percentage not given) (3)
  • 26.
    Consideration: Do OncologyPCMHs Actually Improve Care or Reduce Costs? Evidence • Quality – Evidence Positive for Oncology Medical Homes – Reported Practice Results (4): • ED visits reduced 68% • Hospital Admissions reduced 51% • Avg. LOS reduced 21% • Out Patient visits cut by 22% for all hematology & oncology • Savings of $11,955 per chemotherapy patient • Quality – Mixed Reviews – Particularly Primary Care – “Despite widespread enthusiasm for the medical home concept, few peer-reviewed publications have found that transforming primary care practices into medical homes (as defined by common recognition tools and in typical practice settings) produces measurable improvements in the quality and efficiency of care.” (5)
  • 27.
    Consideration: Do OncologyPCMHs Actually Improve Care or Reduce Costs? Quality Evidence
  • 28.
    RESULTS OF UNITEDHEALTHCARE PAYMENT REFORM PROJECT 28 3 years, 5 sites, 810 Patients, PCMHs Result: Predicted FFS cost = $98M Actual cost = $64M % savings = 34% “There was no difference between the groups on multiple quality measures.” Conclusion: “Modifying the current fee-for-service payment system for cancer therapy with feedback data and financial incentives that reward outcomes and cost efficiency resulted in a significant total cost reduction.” Newcomer LN. Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model. Doi:10.1200/JOP.2014.001488
  • 29.
    UNITED HEALTHCARE COMPENSATIONMODEL “Medical oncologists were paid a single fee, in lieu of any drug margin, to treat their patients. Chemotherapy medications were reimbursed at the average sales price, a proxy for actual cost.” 29
  • 30.
    Our Conclusions RegardingOncology PCMH • PCMHs seem to work quite well in reducing process variation through the use of Pathways – Pathways also can reduce drug costs from process variation – but this is a year 1 & 2 opportunity • PCMHs seem to work quite well in reducing total costs through management of unnecessary hospital admissions and ED use – This is an obvious benefit to the patient – providing the right care, on time and in the right venue • Palliation offered through the PCMH is simply better for the patient and better quality • It is unclear which clinical outcomes measures are impacted by oncology PCMHs
  • 31.
    Medical Home Deliverable Care Considerations  Cancer care that is:  Coordinated with the central focus on the patient and their entire medical condition  Optimized based on evidence-based medicine to produce quality outcomes  Accessible and efficient, with treatment provided in the highest quality, lowest cost setting for the patient  Delivered in a patient-centric, caring environment that optimizes patient satisfaction  Continuously improved by measuring and benchmarking results against other facilities providing care so that best practices “raise the bar” in delivering care Institute of Medicine (IOM) report in 1999, Ensuring Quality Cancer Care
  • 32.
    Oncology Medical Home– Design Considerations -We Match up Pretty Well • Standardized evidence-based guidelines for prevention, diagnosis, treatment, and palliative care - Pathways • Measurement and continuous monitoring of a core set of quality measures – NCQA PCSP Model • Agreed upon care plan prepared by experienced professionals, outlining the goals of care – Care Plans • Access to clinical trials - SCRI • Policies to ensure full disclosure to patients of information about appropriate treatment options – Care Plans, PCSP • Mechanisms to coordinate services – Patient Management • Quality care at the end of life - Palliation • Policies to address the barriers to receiving appropriate cancer care in specific segments of the population – PCSP, Internal Policies Institute of Medicine (IOM) report in 1999, Ensuring Quality Cancer Care
  • 33.
  • 34.
    Other Programs Evaluatedin Our Planning Source: The Advisory Board
  • 35.
    Sites of FocusedStudy • Consultants in Medical Oncology and Hematology, Drexel PA – Level 3 PCSP, led by Dr. John Sprandio – Pioneers in Oncology Medical Home, constant focus on patient engagement and best practice adherence – Proprietary EMR and patient management software – Focused first on Triage, then pro-active patient management – Self Funded Medical Home Development • New Mexico Cancer Center – CoC certified, led by Dr. Barbara L. McAneny – Founder of COME HOME Project, $19.8 million CMMI Grant – Includes 7 practices, and proprietary Pathways and Patient Management software
  • 36.
    Consultants in MedicalOncology and Hematology: Summary Facts
  • 37.
    Consultants in MedicalOncology and Hematology: Methods
  • 38.
    New Mexico CancerCenter & COME HOME
  • 39.
    New Mexico CancerCenter & COME HOME - Methods • Practice Size 10-15 providers – 7 practices • Large emphasis on IP/IT development • Special emphasis on Triage – with proprietary system • Includes Saturday clinic and “after hours” • Multiple layers of patient support • Some practices focused on patient acuity scoring
  • 40.
    Our Distillation: 4Pillars of our Medical Home • Pathways: NCCN compliant Pathways are the base level requirement for our PCMH, Rx, Genetics and Diagnostic imaging – Have to be: • Rigorously and systematically maintained • Independent of any payer organization • Cloud based • Linked to our Aria EMR • Capable of practice level customization • Capable of producing supportive care pathways as well • Capable of easily dealing with our clinical trial volume • Capable of producing Care Plans – Key metrics: 90% Attribution, 80% Compliance
  • 41.
    Pathway System SelectionProcess • All Major commercial systems evaluated – Via Oncology: Not payer or GPO affiliated, excellent clinical content & systems, good patient materials & palliation – P4: Associated with Cardinal and various payer organizations, good clinical content, limited integration with our system – Eviti: Multiple payer customers nationwide, Express Scripts, limited system integration – Clear Value Plus: McKesson product, excellent integration, NCCN affiliation, strong competitor – Flat Iron: Juvenile stage pathway product, Altos EMR tie in, takes all practice data for sale to pharma Via and Clear Value were our 1&2 –We went with Via
  • 42.
    Impact of Pathwayson Compliance Aetna Study
  • 43.
  • 44.
  • 45.
  • 46.
    Care Plans •Care plans: A documented account of care shared with the Patient, Payer and other Providers at transition of care. Form a fundamental information tool with: – Payers: • Care plans form the basis for attribution and compliance metrics • All payer expectations are driven by care plans and subsequent reports/audits • Flexibility in plan design important – Patients: • Plans for the fundamental curriculum around which patient education takes place • Plans form the basis for subsequent patient management – Referrals: • Plans are the fundamental information tool for MU compliance • Plans facilitate continuity of care • Key Metric: Shared with the Patient, Payer and other Providers at 90% of transitions of care, includes all care provided by the practice and additional elements as mandated by Meaningful Use.
  • 47.
    Pathway System AddressesPhase 1 Care Plan Requirement
  • 48.
    Patient Management •Reactive (triage) and proactive management of disease between office visits; systematic response to patient concerns, including non-oncology. Goals: Improved patient care; improved outcomes; reduced cost; increased adherence to care plans. Compliance • Key considerations: – Must offer triage first, then proactive patient management – Must integrate with phone and data management systems – Triage must conform with best practices, and integrate smoothly with scheduling – Must include multi-modal including phone, text, email – Must support development of supportive care pathways with automatic notifications and work lists – Must integrate with Pharmacy • This is a team sport – must include all members of the care team • Key Metric: Control 90% of ED and hospital use
  • 49.
    Patient Management -System Use Cases • Provider – Triage: Safe, timely intuitive triage – Patient management: Supportive care based on predictive pathways – Risk analysis based on clinical data – Frequent periodic patient status/distress reporting • Payer – Timely reports on: triage, status variation, pathway adjustment • Patient – Meaningful and timely educational materials – Direct access to supportive care – Meaningful information regarding status
  • 50.
    Triage/Engagement Considerations TelephonicTriage is a requirement for “Stage 1” Medical Home Development Triage Has three fundamental components  1) Patient engagement and symptom/situation description  2) Tier the patients condition based on objective criteria, reflecting symptoms, history and risk  3) Direct the patient to the most appropriate medical care Triage frequently means late stage correction of a problem - anticipation, training, education should eliminate most triage Triage system needs to be built to accommodate:  1) Broader patient engagement requirements – e.g. status reporting  2) Prospective tiering and planning based on treatment and status  3) Demographic data inputs from EMR
  • 51.
    Validated Tools EdmontonSymptom Assessment System: Edmonton Zone Palliative Care Program: http://www.palliative.org/tools.html
  • 52.
    Validated Tools OntarioCancer Symptom Management: https://smg.cancercare.on.ca/
  • 53.
    Validated Tools TelephoneTriage Protocols for Nurses, Briggs: This is the standard reference in the US. Ideally, we would be able to include in an electronic format.  3 Tier Protocols  Not Optimized to Cancer  Consulting support seems available via Ms. Briggs Emergency Nursing 5-Tier Triage Protocols (also by Ms. Briggs)  Optimized for emergency use  Probably more complicated than needed Telephone Triage for Oncology Nurses, Hickey & Newton:  Optimized for Oncology  Triage protocols are a mix of oncology and other  Needs consistency and standardization
  • 54.
    System Design &Considerations  System built on hosted cloud platform – must be HIPAA compliant  Built around relational data base – tables built from validated sources  Tiering and work-listing for call return & patient response  Maintains and reports real-time on functionality data for system  Integrates with and captures phone system data  Role & Permission based for access and input  Receives ADT feeds for demographic information from demographic master system  Uses standardized and validated patient symptom ranking and distress scoring  Build done in iterative phases:  First – Triage  Second – Patient status reporting (used for outcomes, risk, standardized check-in)  Third – Patient risk/acuity scoring with work-listed outreach requirements  Fourth – Incoming partner data feeds & Date Warehouse  Fifth – Learning system: first focused on actual vs expected, “gamified” to patient
  • 55.
    Patient Management –Predictive Analytics • Initial Objective – Risk for Hospitalization • Key design consideration – based on clinical (EMR) rather than payer data • Must be based on experience in medical oncology – general system not relevant for our needs • Depends on data partnerships with referral hospitals • Evaluated 15-20 systems • Chose Clinicast – group spun out of Kaiser
  • 56.
    Palliation • Integralpart of patient management – we use for all patients (certain clinics), beginning with the first visit • Difficult to justify at the practice level outside of Value Based Care payment model • Moving to patient resources from the pathways system • Really depends on good patient management tools • We applied to participate in the CMMI new palliation model with a local hospice
  • 57.
    57 THE FOURFUNDAMENTALS OF A VALUE-BASED CANCER SOLUTION 4. Palliation -- always relevant throughout the patient’s course of treatment • Alive Hospice / Tennessee Oncology Partnership • Applied for Medicare Care Choices grant, allows for simultaneous curative and palliative care by a non-profit hospice • Pain management • Establishment of patient-driven treatment goals
  • 58.
    58 IN-PATIENT CONTINUESTO DOMINATE EOL COSTS Mean OP chemo cost Mean OP service cost Mean hospice cost Mean IP cost $7,834 $9,230 $10,051 $10,362 $11,469 $25,261 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 6th MBD 5th MBD 4th MBD 3rd MBD 2nd MBD Last MBD Commercial Patients, Mean $/month N = 28,530
  • 59.
    IT System BeforeValue Based Care
  • 60.
    IT System AfterValue Based Care
  • 61.
    The Alternative toPhysician Directed Value Based Care – Aggressive Expansion by PA Companies PA Company Planning documents
  • 62.
    The Alternative toPhysician Directed Value Based Care – Aggressive Expansion by PA Companies PA Company Planning documents
  • 63.
    The Alternative toPhysician Directed Value Based Care – Aggressive Expansion by PA Companies PA Company Planning documents
  • 64.
    VALUE-BASED PERFORMANCE SUMMARYOF KEY CONCEPTS AT TENNESSEE ONCOLOGY  Best care practices  transparency, adherence, and auditability  Patient-Centered Care = Value Delivery Communication of expected outcomes and risks  Communication of costs to patient Empower patients and families to make informed choices  Respect of patients’ decisions and resources  Value delivery achieved through a certified patient-centered medical home  4 pillars: (1) Pathways; (2) Care plans; (3) Patient management; (4) Palliation 64
  • 65.
    Citations 1. NewcomerLN et al: Changing Physician Incentives: An Episode Payment Model. JOP.ASCO. July 14,2014, Published ahead of Print. 2. Feinberg B et al. Third-Party Validation of Observed Savings From an Oncology Pathways Program. American Journal of Managed Care. Volume 19, Special Issue 4. May/June 2013 3. Oncology Business News, August 2014 4. DOI: 10.1200/jop.2014.001386; published ahead of print at jop.ascopubs.org on March 11,2014. 5. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care. JAMA. 2014;311(8):815-825. doi:10.1001/jama.2014.353.

Editor's Notes