The Rise of Oncology Benefit Management Companies: Are They ...

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  • We are going to have fun this weekend. You are a great practice, with wonderful cameraderie amongst yourselves, and we’ll end up with some tangible plans.
    You are going to work hard, and may feel a little shell shocked at times, but I promise you will leave rejuvenated and looking forward to Monday morning and getting started on your new directions.
  • The Genentech Oncology Trend Report was developed to research
    current strategies and perspectives in the management, distribution,
    and reimbursement of treatments for patients with cancer. In the
    spring of 2008, survey instruments were distributed to health care
    professionals within managed care organizations and specialty
    pharmacy providers and to oncologists and oncology practice
    managers. The responses of these four stakeholder groups are
    summarized in the report. It is the hope of all who contributed to
    the report that it will assist in disseminating a range of perspectives
    on the management of cancer treatment, and that it will help clarify
    the points of view and needs of all the stakeholders it represents.
    What follows are primary findings from each of the four surveys.
  • Especially at the negotiating table
  • Forty-two specialty pharmacy professionals responded to a survey designed to gather their views on the management of oncology drugs by specialty pharmacy providers and pharmacy benefit managers.
    Respondents estimated that 21% of their organization’s total revenue, and 16% of their organization’s total prescription volume, is generated from the distribution of cancer medications and adjunctive treatments for cancer.
    Sixty percent of cancer-related revenues for specialty pharmacies is generated by the distribution of cancer medications to patients for self- or home administration. Twenty percent of cancer-related revenues is generated by medications delivered to physicians’ offices for administration in the office, and the remaining 20% is generated by distribution to patients who bring the edication to physicians’ offices for administration there.
  • The Genentech Oncology Trend Report was developed to research
    current strategies and perspectives in the management, distribution,
    and reimbursement of treatments for patients with cancer. In the
    spring of 2008, survey instruments were distributed to health care
    professionals within managed care organizations and specialty
    pharmacy providers and to oncologists and oncology practice
    managers. The responses of these four stakeholder groups are
    summarized in the report. It is the hope of all who contributed to
    the report that it will assist in disseminating a range of perspectives
    on the management of cancer treatment, and that it will help clarify
    the points of view and needs of all the stakeholders it represents.
    What follows are primary findings from each of the four surveys.
  • Being seen across country – what has occurred here?
    CT – no specialty injectables, but in neighboring NY and NJ, wide spread among certain payers
    Interesting that private payers are revising Medicare ASP %s
    Blanket prior auths – as we’ll talk about later, more a knee jerk reaction to a perceived or real problem….Herceptin and United,
    Care Management – know of Quality Oncology?
    More insidious are nurse call centers (payer or vendor) that advise on appropriate care and MDs/ centers – whether or not you know (CIGNA in CT)
    Also watch for ICORE
  • The Rise of Oncology Benefit Management Companies: Are They ...

    1. 1. The Rise of Oncology Benefit Management Companies: Are They Really Medically Necessary? Dawn Holcombe, MBA, FACMPE, ACHE October 8, 2010
    2. 2. Agenda  The models affecting oncology policy and payment in use by payers today:  Identification of the oncology and radiation benefit managers payer use, and what they do  The players and pros and cons for each model  Questions payers and physicians should ask in evaluating potential models  How practices can respond to each model and move toward pro-active payer provider collaborations  How to move forward building your payer oriented program strategy with physician-based medical decision-making
    3. 3. 02/08/0802/08/08 DGH ConsultingDGH Consulting 4401/30/15 DGH Consulting - CONFIDENTIAL 4
    4. 4. The good Old Days (pre-2005) 01/30/15 DGH Consulting - CONFIDENTIAL 555 Employer Payer Provider Rep (IPA, PPO, institution, etc) Provider Patient
    5. 5. 6666 Now 01/30/15 DGH Consulting - CONFIDENTIAL 6 Employer Payer Provider Rep (IPA, PPO, institution, etc) Provider Patient Oncology Manager Pnt mgmnt Drugs, Guidelines, Pathways, Formularies, Credentialling, Authorizations Case mgmnt, disease mgmnt Preferred Provider Accountable Organizations/ Gatekeepers
    6. 6. Standing on Wet Sand  On the Table for Discussion  Oncology Care Venue  Oncology Drug Choices  Oncology Treatment Choices  Window of Opportunity  Taking Charge or  Losing Control
    7. 7. How to Speak with Payers  Recognize their customers and constraints  Collaboration critical for data and analysis  Cancer spend is about 25% MD office and drugs, 75% other. What can you do about both?  Medicine- art and science  Payers – Business, not casual MD to MD  Competitive Messages
    8. 8. Top Payer Goals  Reduce Variation (regimens, drugs, operations, off-label)  Reduce Costs (be aware and make choices, pro-active treatment, compliance management, symptom and adverse event management, end of life process)  Good Business partner (effective, efficient, accountable, proactive) 01/30/15 DGH Consulting - CONFIDENTIAL 9
    9. 9. 01/30/15 DGH Consulting - CONFIDENTIALDGH Consulting - CONFIDENTIAL 10 Issues for Private Payers  Utilization of On-label/ Off-label, even definition  Role of FDA and Compendia, NCCN, ASCO, peer reviewed journals  New drugs cost and management  Patient Responsibility vs Employer Premiums  Oncology transparency, predictability and management  Value vs cost  Common Good/society vs individual  Thresholds for patient/drug/survival benefit vs cost
    10. 10. Changing Payer Perspectives  Oncology No Longer Off the Table  Need Predictability  ?Do we need private practices?  Treat Oncology As a Business and whole, not piecemeal  Preference for Orals vs Infused Oncolytics  Definitions of Need, Appropriate, Outcome, Best, Effective 01/30/15 DGH Consulting - CONFIDENTIAL 11
    11. 11. Where is Patient in Payer Policy?  Battle for Control and Dollars  Management by MDs or others  Patient Portion –  co-pays,  Tiers,  Co-Insurance,  Fixed out of pocket vs Variable,  medical vs pharmaceutical benefit  Value/Benefit Ratios  Survival  Quality of Life 01/30/15 DGH Consulting - CONFIDENTIAL 12
    12. 12. 2008 Oncology Trend Report  Unique cross-industry national survey  Sponsored by Genentech, executed by Kikaku International • Managed Care Professionals • Specialty Pharmacy Professionals • Oncologists • Oncology Practice Administrators and Billing Managers  Disclosure: Dawn Holcombe: Report Chair 01/30/15 DGH Consulting - CONFIDENTIAL 1301/30/1501/30/1501/30/1501/30/15
    13. 13. Managed Care Highlights  90 managed care professionals surveyed re their perspectives on the management of cancer care.  79% expect it will increase in the pharmacy benefit.  61% are neutral or not worried about dropping reimbursements and losing MDs in network  43% expect to require specialty pharmacy for specific drugs in next 12 months  35 – 45% anticipate changes affecting MD drug choices and utilization  67% believe a disease management program would be effective in managing cancer costs  72% offer case management to patients  2008 Oncology Trend Report, Page 3 01/30/15 DGH Consulting - CONFIDENTIAL
    14. 14. Perspective is Everything 5 Views of Main Street/Oncology
    15. 15. Specialty Pharmacy Highlights  42 specialty pharmacy professionals - management of oncology drugs by specialty pharmacy providers and pharmacy benefit managers.  21% of total revenue, and 16% of total prescription volume  60% cancer-related revenues for specialty pharmacies  Oral cancer medications -26% of all cancer-related prescriptions distributed through specialty pharmacy. (Self-injected cancer therapies , 33%; adjunctive cancer therapies, 16%; office-based infusions, 13%; and office-based injections, 12%. )  81% provide patient education and medication disease management  74% compliance and persistence programs  69% patient care coordination programs.  2008 Oncology Trend Report, Page 3 01/30/15 DGH Consulting - CONFIDENTIAL
    16. 16. Oncologists Highlights  139 oncologists surveyed on provision of cancer care.  64% - workloads have increased in the past year.  39% - income fallen in past 2 years .  58% - identifying revenue loss therapies (42% have not)  69% - consider referring patients to hospital for financial loss therapies  2008 Oncology Trend Report, Page 3 01/30/15 DGH Consulting - CONFIDENTIAL
    17. 17. Does Your Practice Encourage or Require the Use of Clinical Guidelines for Treatment of the Following Cancers? 01/30/15 DGH Consulting - CONFIDENTIAL 2008 Oncology Trend Report, Figure 63 Page 30
    18. 18. If Your Practice Encourages or Requires the Use of Clinical Guidelines, How is Adherence to Guidelines Encouraged or Enforced? 01/30/15 DGH Consulting - CONFIDENTIAL 2008 Oncology Trend Report, Figure 65 Page 30
    19. 19. Oncology Admin. Highlights  60 reported on Practice management, billing and reimbursement  60% payer contracts mostly favorable, 23% - not, 17% don’t know  19% - do not negotiate fee schedules  35% - try to negotiate fee schedules but are generally not successful.  21% - do not know contract collectibles  21% - know contract collectibles, but not if they are paid correctly  2008 Oncology Trend Report 01/30/15 DGH Consulting - CONFIDENTIAL
    20. 20. 2010 Oncology Trend Report  Cross-industry national survey  Sponsored by Sanofi Aventis, executed by Kikaku International • Managed Care Professionals • Oncologists  Disclosure: Dawn Holcombe: Report Chair 01/30/15 DGH Consulting - CONFIDENTIAL 2101/30/1501/30/1501/30/15
    21. 21. Managed Care Highlights  80 managed care professionals surveyed  Although 73.5% of cancer spend is in the medical benefit, 52.5% expect it will increase in the pharmacy benefit.  55.1% encourage, but do not require, use of spec. pharmacy.  9.7% of cancer spend is in oral drugs  35.4% have a preferred relationship with one or more specialty pharmacies in regard to oral cancer drugs.  Oncology management measures: 46.3% - require step therapy, 46.3% require lab values, 48.7% prior authorization rules toward preferred agents, and 38/8% require compendia positioning  30% have collaborative oncologist relationships, 40% planning to develop  34.2% report oncology MD communications as ad hoc, 25.5% as professional, and 15.4% as collaborative  2010 Oncology Trend Report, Page 22-27 01/30/15 DGH Consulting - CONFIDENTIAL
    22. 22. MCO Interest in Collaboration by Program Type  Interest level for collaborating with payers on programs (using a scale of 1 to 5, where 1 = little interest and 5 = intense interest)  Improvements in quality measures for plan satisfaction 3.9  Care cost and evaluation 3.8  Hospitalization avoidance 3.8  End-of-life process 3.7  Reduction of variation (guidelines) 3.7  Targeted reduction of preferred treatment options (pathways) 3.7  Pain management programs 3.5  Patient symptom/side-effect management programs 3.5  Risk-based reimbursement programs 3.5  Bundled reimbursement programs 3.3  Off-label programs, tracking, and compliance 3.3  Participation in ASCO’s Quality Oncology Practice Initiative 3.2  Advisory panel 3.2  Survivorship management programs 2.9 2010 Oncology Trend Report, Page 22-27 01/30/15 DGH Consulting - CONFIDENTIAL
    23. 23. Oncologists Highlights  163 oncologists surveyed on provision of cancer care.  29.6% 1-2 MDs, 27% 3-4 MDs, 23.7% 5-6 MDs, 9.5 7-9 MDs, 9.2% 10+ MDs.  49.7% use EMRs, but more than half use primarily for routine operational tasks. 42.5% do not collect data. 21.6% able to leverage data for $ or other.  62-66% follow guidelines, but 50% of those monitor compliance. Only 13.5% integrated guidelines into EMRs.  54.7% do not accept drugs from specialty pharmacy to practice, and 69.2% do not accept to patient. 88.6% would require liability waiver. 31.5% use spec. pharmacy for 5% or less of drugs, 78.3% use spec. pharmacy for less than 20% of drugs.  28.6% feel unable to negotiate fees with payers. 57.9% feel able to negotiate with limited success.  63.2% have identified revenue losses for treatments (36.8 have not).  41.1% expect some affiliation or alliance change in future, 43.4% expect no change.  37.9% say relationships with payers around annual contracting.12.4% felt communications were strained, 11.9% said neutral, and 10.2% said collaborative.  2010 Oncology Trend Report, Page s 14 - 21 01/30/15 DGH Consulting - CONFIDENTIAL
    24. 24. MD Interest in Collaboration by Program Type  Interest level for collaborating with payers on programs (using a scale of 1 to 5, where 1 = little interest and 5 = intense interest) 1. Improvements in quality measures for plan satisfaction (MCO 1) 3.1 2. Patient symptom/side-effect management programs (MCO 8) 3.1 3. Participation in ASCO’s Quality Oncology Practice Initiative (MCO 12) 3.1 4. Care cost and evaluation (MCO 2) 3.0 5. Hospitalization avoidance (MCO 3) 3.0 6. Advisory panel (MCO 13) 2.9 7. End-of-life process (MCO 4) 2.9 8. Off-label programs, tracking, and compliance (MCO 11) 2.8 Reduction of variation (guidelines) (MCO 5) 2.7 9. Targeted reduction of preferred treatment options (pathways) MCO (6) 2.7 10. Pain management programs (MCO 7) 2.7 11. Risk-based reimbursement programs (MCO 9) 2.7 12. Survivorship management programs (MCO 14) 2.7 13. Bundled reimbursement programs (MCO 10) 2.5 14. Contract Capitation (mutually agreed) (no MCO ?) 2.4 2010 Oncology Trend Report, Page 22-27 01/30/15 DGH Consulting - CONFIDENTIAL
    25. 25. The Secret to Success  It’s Really About Medical Decision-making, Not Drugs  Continuum  Care  Cost  Comparativeness
    26. 26. Models in Play for Oncology  Drug Management  Disease Management  Specialty Pharmacy/Pharmaceutical Benefit  NO MD infusion at all  Oncology Management  Radiation Oncology Benefit Management  MD Collaborations  Front End Compliance Programs  Back End Compliance Programs 01/30/15 27
    27. 27. Drug Management  Primary Focus: Drugs - preferred product pricing, formulary, authorization process  ICORE, CareCore Oncology, specialty pharmacies, P4Healthcare (Cardinal)  MD Involvement – none  Payers – $$, easy to understand  MDs– Negative Impact/Interactions with MDs  Pharma – disconnect with pricing, MDs 01/30/15 DGH Consulting - CONFIDENTIAL
    28. 28. Drug Management Report Card  Savings  Yes, depending on prior fees  Sustainable  Yes  No  Effect on Oncology Spend  Limited  Potential Success as Oncology Mgmnt Tool – D 01/30/15 DGH Consulting - CONFIDENTIAL
    29. 29. Disease Management  Primary Focus – Manage symptoms and side effect of oncology disease and treatment  Present in every oncology practice, not always formalized or tracked  Quality Oncology (Alere), Innovent Oncology New entrant), ICORE  MD Involvement – Must have Tx plan and care info from practice (usually not reimbursed and difficult to obtain)  Payers– formalized programs and tracking, essential part of daily cancer care  MDs – intrusive, redundant with much of practice care  Pharma – disconnect with MDs and call centers 01/30/15 DGH Consulting - CONFIDENTIAL
    30. 30. Disease Management Report Card  Savings  Not proven over long term  Sustainable  Yes  No  Effect on Oncology Spend  Limited  Potential Success as Oncology Mgmnt Tool – D 01/30/15 DGH Consulting - CONFIDENTIAL
    31. 31. Specialty Pharm/Pharm Benefit  Primary Focus – Shift oncology care to pharmaceutical benefit and/or provision of drugs through specialty pharmacy  Most oncology drugs are provided through offices and buy and bill  Specialty Pharmacies/PBMs  MD Involvement – Order, receive, store, provide/distribute (Retain liability)  Payers– tracking and monitoring, benefit design control  MDs – issues: liability waiver, waste 01/30/15 DGH Consulting - CONFIDENTIAL
    32. 32. Spec Pharmacy Report Card  Savings  Yes/No  Sustainable  Yes/No  Effect on Oncology Spend  Limited  Potential Success as Oncology Mgmnt Tool – C 01/30/15 DGH Consulting - CONFIDENTIAL
    33. 33. Retail Infusion Centers  Primary Focus – Shift oncology treatment to freestanding infusion centers, away from physician or hospital-based centers  80+ % of care provided in physician center, rest in hospital centers  Potentially large pharmacy chains or mass market stores with clinical offices  MD Involvement – diagnose, Order, medical supervision and management(Retain liability)  Payers– mass contracting  MDs – issues: liability, medical management complications, complex oncology not like kidney dialysis with one drug 01/30/15 DGH Consulting - CONFIDENTIAL
    34. 34. Retail Infusion Centers Report Card  Savings  Yes/No  Sustainable  Jury Out  Effect on Oncology Spend  Infusion costs – Yes  Total Costs – Not yet proven yes or no  Potential Success as Oncology Mgmnt Tool – C 01/30/15 DGH Consulting - CONFIDENTIAL
    35. 35. Radiation Oncology Benefit Management ROBM, RBM  Primary Focus: utilization management, prior authorization, approval logarithms, Cost control, patient advocacy (use, medical approp., safety)  CareCore National, American Imaging Mgmnt (Anthem). National Imaging Assoc. (Magellan), MedSolutions, HealthHelp  MD Involvement – none, ASTRO “Quality of Care Concerns” http://www.astro.org/PublicPolicy/WhitePapersAndOtherDocuments/ documents/ROBM.pdf  Payers – External company as buffer between MDs and payer, short term savings  MDs– Negative reactions from MDs, short term results, wall between MDs and payers  “Appropriateness criteria..denials…costs…medical necessity 01/30/15 DGH Consulting - CONFIDENTIAL
    36. 36. Radiology Onc Ben Mgmt Report Card  Savings  Yes/No  Sustainable  Jury Out  Effect on Oncology Spend  Radiology costs – Yes  Total Costs – Not yet proven yes or no  Potential Success as Oncology Mgmnt Tool – C 01/30/15 DGH Consulting - CONFIDENTIAL
    37. 37. Oncology Management  Primary Focus: "Rational physician reimbursement", utilization management, prior authorization, approval logarithms  ICORE, Medco  MD Involvement – none  Payers – External company as buffer between MDs and payer, short term savings  MDs– Negative reactions from MDs, short term results, wall between MDs and payers  Pharma – disconnect between MDs, OMs 01/30/15 DGH Consulting - CONFIDENTIAL
    38. 38. Oncology Management Report Card  Savings  Yes, short term  Sustainable  limited  Effect on Oncology Spend  Drug costs – short term yes  Total Costs – Not yet proven yes or no  Potential Success as Oncology Mgmnt Tool – D 01/30/15 DGH Consulting - CONFIDENTIAL
    39. 39. Role of BCBS FL for ICORE  Projected to save $71 million  MDs not involved  “We believe that over the next several years, oncology benefits management will be an important component of the services and expertise we offer and a material part of our overall business” 2008 Annual Report, Magellan Health Services 01/30/15 DGH Consulting - CONFIDENTIAL
    40. 40. Market Position ICORE  Managed Care Oncology – 900 payers, 100 payer vendors, 4000 oncologists  2009 Media Kit “Sources information chemotherapy trends?” • NCCN 79% • Managed Care Oncology 74% • ASCO 68% • Journals 50% • Medical meetings 44% • Colleagues 38% • Resources – Compendia etc 38%  7th Annual Oncology summit NYC, Sept 10/11 01/30/15 DGH Consulting - CONFIDENTIAL
    41. 41. Rapid Expansion  Magellan purchased First Health (Medicaid plan) from Coventry July 2009  Included provision that ICORE oncology management services will be executed in 5 Coventry Markets before end of 2009  Missouri, all public and private Coventry members (GHP)  Virginia (Southern Health)  PA?  “Magellan Health (MGLN) to Aquire First Health Services from Coventry (CVY) for $110 M”, Magellan Health Services News Release, June 5, 2009, Last accessed on August 30, 2009 at: http://www.streetinsider.com/Mergers+and+Acquisitions/Magellan+Health+(MGLN)+to+Acquire+First+Health+Services+from 01/30/15 DGH Consulting - CONFIDENTIAL
    42. 42. MD Collaborative Programs  Straight Line most cost effective  “Team” collaboration = health care reform instead of collisions  Engagement demands culture approach, not piecemeal  Process vs outcomes (like step therapy)  Real change is evolution, dollars and action  Very transitional – room to explore 01/30/15 DGH Consulting - CONFIDENTIAL
    43. 43. MD Collaborative Programs Report Card  Savings  Yes, short term and long term - different  Sustainable  indefinitely  Effect on Oncology Spend  Yes, evolutional, more than self limiting  Potential Success as Oncology Mgmnt Tool – A 01/30/15 DGH Consulting - CONFIDENTIAL
    44. 44. Flexibility and Preparation the Key  No one size fits all answer  Do homework first, and consider facilitation  You don’t need a middleman to negotiate for you……but possibly with you  Payer speak essential  Cast a wide net, don’t narrow your vision  “Step-collaboration”, like step therapy
    45. 45. Wide menu of Collaborative Program Topics  ASCO’s QOPI participation  Pathways (≠ guidelines)  Variation and Standardization (Process vs Outcomes)  Premium or at risk payments  Imaging or diagnostics costs  Continuum of Care/Registries/Experience  Proof of implementation/process/execution  Compliance with ______ (guidelines, pathways, off label, planning, process, formulary, etc.  Role of Specialty Pharmacy, Disease Management  Programs – Survivorship, End of Life, Symptom Mgmnt 01/30/15 DGH Consulting - CONFIDENTIAL
    46. 46. Front End Compliance Programs (Pathways)  Primary focus: Support Evidence based medical decision-making by MD at point of decision by pathways monitored, maintained by MDs  Via Oncology, Innovent Oncology, NCCN (Proventys)  MD Involvement – for every patient, every key medical decision  Scope: Up to 17 diseases, with up to 520+ branches for single best choice tailored to state and stage of disease  Payers: MD buy-in, Web Portal, current payer/MD contracts , Tracks and monitors compliance as well as reasons for non- compliance, applicable for hospitals as well as MD groups  Issues: Requires MD payer joint collaboration, not a remote third party solution, once MDs buy in to pathways, easier to implement across all payers and patients than any one payer 01/30/15 DGH Consulting - CONFIDENTIAL
    47. 47. Front End Compliance Report Card  Savings  Yes, short term and long term  Sustainable  indefinitely  Effect on Oncology Spend  Yes  Potential Success as Oncology Mgmnt Tool – A 01/30/15 DGH Consulting - CONFIDENTIAL
    48. 48. Back End Compliance Programs (Preferred treatments)  Primary focus: Tracking care through post treatment claims data against multiple approved preferred treatment choices; and drug margin preferencing  P4 Healthcare (Cardinal), ION Pathways (in development)  MD Involvement – pathway development by MDs, varying degrees of negotiating, limits?  Scope: Usually 3-4 major diseases in first year, with subsequent expansion , multiple care choices per disease, collect all practice claims data – additional paper info added only for select patients  Payers: P4 – existing payer contracts, limited time of MD required ION – practice enters data in ION software (easier if client), can reach greater depth than P4 model  MDs: P4 cookie can collect more data than contract requires, limited reporting capability (P4), limitations in insight into medical decision-making, does not track clinical trials or reason for non-compliance, some contracting focuses only on drug margins, multiple choices questioned as more guideline than pathway model01/30/15 DGH Consulting - CONFIDENTIAL
    49. 49. Back End Compliance Report Card  Savings  Yes, short term and long term (but is menu sufficient?)  Sustainable  Yes/No (Carefirst changes in 2010)  Effect on Oncology Spend  Yes, evolutionary, but reporting somewhat limited  Potential Success as Oncology Mgmnt Tool – C/B (where MDs not engaged – D) 01/30/15 DGH Consulting - CONFIDENTIAL
    50. 50. New Strategy Required for MDs  Decide your own role and direction  Quality in eye of beholder – PROVE YOUR VALUE  Common Business Sense Matters  New Message – in competitive market  Size/affiliations Matters  Quality Matters  Overhead/Business Savvy (Strategy) Matters  Full Continuum of Care/Service matters 01/30/15 DGH Consulting - CONFIDENTIAL
    51. 51. Purpose of Oncology Management  Right care, right setting, right time  Reduction of variation has value for all involved, with nod to oncology complexity and medical decision-making  MD engagement or control  Penny-wise, pound foolish (total spend vs drug spend  Data sharing (vs missing pieces)  Importance of reporting as proof  Journey vs step  Administrative costs vs medical costs
    52. 52. Considerations  Pathways (When is a pathway not a pathway?) follow the $  Claims data limitations  Preferential pricing (Product Preferencing)  Rational Reimbursement  Gainsharing  Brownbagging/Whitebagging  $ and Success Impact: Collaborate/Colliding
    53. 53. 01/30/15 54DGH ConsultingDGH Consulting Focused Initiatives DGH Consulting - CONFIDENTIAL
    54. 54. Current MD Focused Programs  Front End  University of Pittsburgh Medical Center (UPMC)/Highmark BCBS, Horizon BCBS (VIA Oncology)  USON pilots/United and Anthem Wellpoint/(Innovent Oncology), Aetna  Back End  Michigan/BCBS Michigan, Highmark BCBS  P4/Carefirst BCBS, Capitol BCBS, TN 01/30/15 DGH Consulting - CONFIDENTIAL
    55. 55. Examples, continued  Other  CCE Cancer Clinics of Excellence/Anthem Wellpoint  CCE Cancer Centers of Excellence (NCCN)/United  United NCCN Compendia claims submission policy/national  Cancer Care Northwest/Premera BC (private pilot )  New Century Infusion Solutions/Medicare MA plans in FL  United Evidence Based Pilot (up to 6 practices) 01/30/15 DGH Consulting - CONFIDENTIAL
    56. 56. Marriage Counseling - Laying common Ground work – Caution, Full Speed Ahead May Cause Unintended Consequences  Payers  Oncology a black box  Challenges and issues  Realities of Medicare (former role model)  Process vs outcomes 01/30/15 DGH Consulting - CONFIDENTIAL  Physicians/Centers  Proof of value/quality  Payer challenges and issues  Realities of Future and external players  Process vs outcomes External Managers: We can manage “cowboy physicians” MDs: Let’s collaborate and manage the full costs and aspects of quality oncology care, using evidence based medicine.
    57. 57. FAQ for every model  Transparency  Collaboration  Business Partner  MD Involvement  Non MD partners  Software, Data  Customer  Payer Negotiation  Strategic Direction 01/30/15 DGH Consulting - CONFIDENTIAL
    58. 58. New Delivery Models – Major Implications  Physician (private, group, network)  Professional Services only  Full Oncology Services  Hospital/Integrated system (existing or expanded)  Academic Center Expansion  Corporate Infusion Clinics (Walmart, eg)  Regional MD or Hospital Infusion clinics 01/30/15 DGH Consulting - CONFIDENTIAL
    59. 59. New Strategy Required for MDs  What role do you want to play?  What message/project list will you take in to payer meeting?  Common Business Sense Matters – Do you know your numbers?  Learn New Language (s) for Better communication  Size/affiliations Matters  Quality Matters  Overhead/Business Savvy (Strategy) Matters  Full Continuum of Care/Service matters 01/30/15 DGH Consulting - CONFIDENTIAL
    60. 60. Pharma Strategy  Encourage Payer/MD collaborations as much as possible  Bridge facilitators for payers and MDs, rather than contracted managers  Watch for limited models and ripple impact on MDs and patients of external vendors  Oncology spend encompasses far more than just drugs. 01/30/15 DGH Consulting - CONFIDENTIAL
    61. 61. Are Oncology Benefit Management Companies Medically Necessary?  No – if the oncology medical community is proactive with payers about collaborative models, and focuses on reducing variation, reducing cost, and being a good business partner  Yes – if oncology medical community does not do the above
    62. 62. Summary  Oncology is about far more than drugs (75% +)  Not all distribution/delivery models are right for oncology  Business of oncology is changing – keep good  Effective, evidence based tools that work in concert with care providers are now available  Lone wolves run in a pack when times are tough.  Mantra: Size Matters, Overhead Matters, $ for Benefit Matters, and Quality Matters
    63. 63. 01/30/15 Thank You, and Good Luck Dawn Holcombe, MBA, FACMPE, ACHE DGH Consulting 33 Woodmar Circle South Windsor, CT 06074 860-305-4510 860-644-9119 fax dawnho@aol.com www.dghconsulting.net 01/30/1501/30/15 DGH Consulting - CONFIDENTIAL

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