ASCO Update: Shaping
Public Policy in a National
Organization
Hawaii Society of Clinical Oncology
Ray Page, DO, PhD, FACOI
President,Texas Society of Clinical Oncology
President,The Center for Cancer and Blood Disorders,
Fort Worth,TX
November 14, 2015
Financial Disclosure
• No discussion of off label prescribing
• I currently have the following relevant financial
relations to disclose:
»Consultant: Via Oncology
»Speaker’s Bureau: Biodesix
Outline of Presentation
•
•
•
•
State of Cancer Care 2015
Economic burden of health care costs
SGR
MACRA
ASCO Patient Centered Oncology Payment
Program
• Oncology Medical Home/Payment Models
• Oncology Pathways
The State of Cancer Care
in America: 2015
www.ASCO.org/StateofCancerCare
More Oncologists Over 64
Than Under 40
Oncologists Experiencing Burnout
• Nearly 50% of oncologists
experience burnout
• 80% would choose to be
oncologist again
• 34% of fellows reported
high levels of burnout
• New oncologists desire to
work fewer hours than
current oncologists
Rough Waters
for Practices
• Implementing evidence-based
medicine
– Often not sufficient evidence, but increasing desire for
precision medicine
– Lack of uniform standards for quality & performance
• Economic pressures
• Increasing administrative requirements
• Adjusting to new payment models
– Greater financial risk
Practice Pressures
Source: ASCO Annual Practice Census 2014
Smaller Community Practices at Risk
• Backbone of U.S. cancer care delivery system
• Serve more than one-third of all new patients,
especially in the South
• Smaller practices more likely to merge, sell, or
Small Practices Responding by Census Region
close in the next year
20%
– 16% Merge
18%
– 12% Sell
14%
– 10% Close
16%
12%
Merge
10%
Sell
8%
Close
6%
4%
2%
0%
Midwest
Northeast
South
West
111 practices 70 practices 142 practices 125 practices
Economic Burden of Healthcare
Costs
US Health Spending at 17.7% of GDP is ~50%
Greater than Others (and Still Rising)
Projected US Health Spending 2020 → 20% GDP
Kehhan SP, Cuckler GI, Sisko AM, Madison AJ, Smith SD, Lizonito JM, Poisal JA and olfe CJ. National Health Expenditure Projections: Modest Annual Growth
Until Coverage Expands And Economic Growth Accelerates. Health Affairs. 2012 Jul;31(7):1600-12.
Hospitals and Providers a large fraction
US Healthcare Spending
Cost Drivers of Cancer Care
•
Life threatening disease-desperate situations/desperate
patients and families
•
Excessive expenditures near end of life
•
New, costly technologies are rapidly emerging-not all fully
evidence-based
•
Complex cancer care not well coordinated
•
Payment system is not aligned with the goals of the
healthcare system
•
No pricing constraints in U.S.
Cancer Costs Skyrocketing
Cost of Cancer Care is Rising
→ $125 billion in 2010
→ $175 billion in 2020
Cost of Recently Introduced Targeted
Therapies for Cancer
Kantarjian, H, et. al., JCO 31: 3600, 2013.
Adverse Effects on Patient Care
20% of patients
took less than
prescribed amount
High Out of
Pocket
Cancer Care
Costs
24% avoided
filling
prescriptions
19% partially
filled
prescriptions
Source: Zafar SY, Peppercorn JM, Schrag D, et al: The
financial toxicity of cancer treatment: A pilot study assessing
out-of-pocket expenses and the insured cancer patient’s
experience. Oncologist 18:381-390, 2013
Patients are Bearing
More of the Costs
Household Income
Projected family health insurance premium costs and
average household income
Annals of Family Medicine: 2012: 10: 156-162
Year
Patients Want to Discuss Cost
Source: Bullock et al JOP 2012
Cancer care costs rising faster than overall
healthcare
Cancer Drugs
Cancer
Medical
Healthcare
US GDP
Source: Blue Cross Blue Shield Association
Bending the Cost Curve
•
•
•
•
•
Patient-centered discussion of options
Physician payment reform
Price negotiation by CMS
Value-based reimbursement
Indication-specific pricing
A New Acronym
Medicare Access and CHIP
Reauthorization Act
MACRA
MACRA
MACRA
MACRA
SGR
H.R. 2
• Repeals (SGR)
• Extends Children’s Health
Insurance Program
• Streamlines federal
reporting programs
• Incentivizes participation in
alternative payment models
Passed House
(392 – 37)
Continued Shift From
Fee For Service
" …moving away from the old way
of doing things, which amounted to
'the more you do, the more you get
paid.”
-Sylvia M. Burwell
HHS Secretary
SGR is Repealed
…MACRA Creates two tracks for providers
This is NOT in the distant future
•
HHS required to publish final plan for MIPS and APM
measure development by May 1, 2016
•
First list of measures to be published Nov 1, 2016
•
HHS may contract with physician organizations to develop
measures
MIPS: General Structure
• Excludes physicians in alternative
payment model
• Starts 2019--based on 2017
performance
• Penalties/bonuses budget neutral,
so bonus size dependent on how
many people get penalties
• Scores will be reported publically in
Physician Compare
• “Exceptional” practices could win
extra 10% bonus funded with
$500m in new money
Merit-Based Incentive Payment System
(MIPS)
Meaningful Use
(MU)
Physician Quality
Reporting System
(PQRS)
Value Based
Modifier (VBM)
MIPS
MIPS Potential Impact
High Performers
Resource
Use
+27%
+
Quality
Reporting
Composite
Score
1-100
EHR
MU
Threshold
Flat
Clinical
Improvement
Activities
Low Performers -9%
MIPS Composite and Potential Impact
Meaningful Use
15%
25%
PQRS (Quality)
Resource Use (Cost)
30%
30%
Clinical Improvement
(Patient Satisfaction,
Care Coordination, etc.)
0
Low Performers -9%
National Median Composite Score
Medicare Provider Composite Score
100
High Performers +27%
HHS Goal:
By 2018,
50% of all
Medicare
payments
based on
alternative
models
What is An Alternative Payment Model
(APM)?
• Comprises “significant” share of provider revenue
– 25% 2019-2020
– 50% 2021-2022
– 75% 2023 and on
• Carries two-sided risk
• Includes financial incentives (e.g., bonus, shared savings)
• Includes quality measurement
Alternative Payment Models
Accountable Care Organizations
Primary Care & Medical Home Models
Bundled Payment Initiatives
Integrated Care & Care Management
Oncology Care Model (OCM)
CMMI Developed Pilot Targeting 100 Practices
• $160/month care management fee
– Additional payment adjustment based on savings
– 6-month episodes triggered by chemo (oral or infused)
– No limit on number of episodes
• Requirements
– 24/7 patient access to clinician with real-time access to patient’s
medical records
– ONC-certified EHR
– Attest to Stage 2 of meaningful use (MU) by end of year 3
– Utilize data for continuous quality improvement
– Provide core functions of patient navigation
– Documented care plan containing all 13 IOM components
– Treatments consistent with nationally recognized clinical guidelines
Will HHS Reforms Make Sense in Oncology?
The Oncology Care Model
• Relies on broken fee for
service
• Oncologists cannot control
all aspects of spending
• Cancer care does not fit
into 6-month episodes
• Seems designed only for
large practices
• Only 100 practices can
participate
MACRA Bottom Line
• Strong incentives to participate in APMs
• Consolidated quality reporting incentivizes participation in
qualified clinical data registries
• Will motivate practice transformation/infrastructure
• Implementing rules will be critical, e.g.,
− Defining and assigning risk
− Determining appropriate quality measures
Why Fee For Service
Doesn’t Work
• Low or no payment for:
–
–
–
–
–
Patient education
Nursing evaluation & care coordination
Social work, financial counseling, nutrition
Survivorship & palliative care
Cost and use of innovative technology
• Loss of revenue if fewer or lower cost treatments
are given or oral drugs used
• No payment for work outside of face to face
encounters
Moving Away from Fee for Service
ASCO Patient Centered Oncology Payment
(PCOP)
• Add new codes to existing E&M codes to cover cost of
services
• Replace E&M codes with monthly payment codes that
provide flexibility in how care is delivered
• Bundled monthly payments that include both oncology
practice costs and other costs such as tests, avoidable
hospitalizations, and/or drugs
Accountability in all three—but for things oncologists can control
ASCO’s Efforts to Respond to
Payment Reform: ASCO’s Cancer
Care Payment Model
ASCO’s Efforts to Respond to
Payment Reform
• Promoting Adherence to Evidence-Based Medicine:
– ASCO Guidelines
– “Choosing Wisely” Campaign
– Clinically Meaningful Outcomes in Cancer Research
• Commitment to Quality Improvement:
– Quality Oncology Practice Initiative and Training Program
– Virtual Learning Collaborative to Improve Palliative Care
– Cultivating a learning healthcare system: CancerLinQ
• Supporting Value Purchasing and Considerations:
– Developing tools to support physician-patient value discussion
– Payment Reform Model
The ASCO Payment Reform Premise
• Oncology Costs are a large and growing percentage
of healthcare spending
• Oncologists can be part of the solution
• There are proven methods to reduce oncology costs
and promote quality of care
• Requires practice transformation and resources
• MACRA legislation promotes Advanced Payment
Models
• The ASCO Patient Centered Oncology Payment
model facilitates enhanced patient care coordination,
quality of care, and leads to reduced costs
ASCO Payment Reform Workgroup Members
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Anupama Acheson, MD*
Jeffery Ward, MD*
Robin Zon, MD, FACP, FASCO*
Andrew Hertler, MD, FACP
Blasé Polite, MD, MPH
Christian A. Thomas, MD
Dan Zuckerman, MD
Denis Hammond, MD
Ed Balaban DO, FACP, FASCO
James Frame, MD, FACP
Joel Saltzman, MD
John Cox, DO, FACP, FASCO
John Hennessy, CMPE
Michael Diaz, MD
Omar Eton, MD
Ray Page, DO, PhD, FACOI
Rena Conti, PhD
Roscoe Morton, MD, FACP*
W. Charles Penley, MD, FASCO
Kavita Patel, MD, MS
Harold Miller
Don Moran/Kevin Kirby
Deborah Kamin, PhD
Providence Oncology and Hematology Care Clinic
Swedish Cancer Institute Edmonds, WA
Michiana Hematology Oncology
New Century Health
The University of Chicago – Oncology
New England Cancer Specialists
Mountain States Tumor Institute
New Hampshire
Penn State Hershey Medical Center
Charleston Area Medical Center
Lake Health University Hospital Seidman Cancer Center
UTSW Parkland
Sarah Cannon Cancer Services
Florida Cancer Specialists
Boston University Medical Center
Center for Cancer and Blood Disorders – Texas
The University of Chicago
Medical Oncology and Hematology Association
Tennessee Oncology
Brookings
Center for Healthcare Quality and Payment Reform
The Moran Company
ASCO
Payment Reform Principles
•
•
•
•
•
•
Multiple, flexible models
Allow practice evolution
Facilitate care delivery innovation
Emphasize comprehensive patient care
Reward outcomes (over process)
Reward cost containment
ASCO’s Approach to
Oncology Payment Reform
Oncologists
Identify What’s
Needed for HighValue Cancer
Care
Design Changes
In Payment to
Support PatientCentered Care
Better Care,
Lower Spending,
Practices Stay
Financially
Viable
Most Oncology Spending Does
Not Go to the Oncology Practice
Current
Spending
Per Patient
$45,000
$40,000
ER/Hospital
Admissions
$35,000
Other
Services
$30,000
Testing
90%+ of spending pays for drugs,
laboratory tests, imaging studies,
surgical procedures, emergency
room visits, and hospitalizations
$25,000
$20,000
$15,000
Drugs
$10,000
$5,000
$0
E&M
Infusions
Fees for oncology practice services
represent less than 10% of spending
for cancer patients during
episodes of chemotherapy treatment
Analysis of total spending in 2012 for commercially insured patients
during an “episode” of chemotherapy treatment
(treatment months through the second month after treatment ends)
Most Oncology Drug Spending is
Driven By a Few Expensive Drugs
Significant savings possible through more appropriate use
Reductions in 3 Potentially Overused
Drugs Creates Significant Overall
Savings
Most Imaging Costs Result From a
Few Types of Imaging Studies
Most Testing Costs Result from a Few
Frequent or High Cost Tests
25%+ of Admissions Are Likely
Complications of Treatment
Large Reductions in Avoidable
Hospitalizations Are Possible
Source: Sprandio JD.
“Oncology patientcentered medical home
and accountable cancer
care.”
Community Oncology,
December 2010
Spending on Drugs, Imaging, and
Hospitals Varies by More Than 60%
$4,189
$2,700
$3,656
Source:
Clough, Patel, Riley,
Rajkumar, Conway,
Bach.
"Wide Variation in
Payments for
Medicare
Beneficiary
Oncology Services
Suggests Room for
Practice-Level
Improvement."
Health Affairs,
April 2015
Savings From Better Care
The
Transformation of
Oncology Payment
www.asco.org/paymentreform
ASCO Model
Patient-Centered Oncology Payment
Payment Reform to Support Higher Quality, More Affordable Cancer Care
• 3 options with transition away from fee-for-service
– Add new codes to existing E&M codes to cover cost of
services
– Replace E&M codes with monthly payment codes that
provide flexibility in how care is delivered
– Bundled monthly payments that include both oncology
practice costs and other costs such as tests,
hospitalizations and/or drugs
• Episode of chemotherapy (IV or oral)
• Accountability in all three options… but for things
oncologists can control
Opportunities to Reduce Spending During
an Episode of Chemotherapy
Current
Spending
Per Patient
$45,000
$40,000
$35,000
ER/Hospital
Admissions
Other
Services
$30,000
Testing
$25,000
Avoidable $
$20,000
$15,000
Drugs
$10,000
$5,000
$0
• ED visits and hospital admissions
for chemotherapy-related complications
E&M
Infusions
• Unnecessarily expensive tests
• Unnecessary testing
• Unnecessarily expensive drugs
• Unnecessary drugs
• Unnecessary end-of-life treatment
Payments Do Not Match Activity
Diagnosis, Choosing Therapy, Counseling
$1000
PHYSICIAN/STAFF
TIME/COSTS FOR
CANCER CARE
Therapy & Preventing Complications
$750
Monitoring & Support
$500
$250
$0
$1000
0
Dx
1
2
3
4
5
6
TREATMENT MONTHS
7
8
9
10 11
EM
EM
EM
EM
EM
E&M
E&M
EM
Infusion
Infusion
E&M
Infusion
E&M
E&M
$0
EM
$250
Infusion
$500
HOW ONCOLOGY
PRACTICE IS PAID
E&M
Infusion
$750
12 13 14 15
POST-TREATMENT CARE
Pay for Care Management (PCOP Level 1)
Cancer Care
Spending
Per Patient
$45,000
$40,000
ER/Hospital
Admissions
$35,000
Other
Services
$30,000
Testing
$25,000
Avoidable $
$20,000
$15,000
Drugs
$10,000
$5,000
$0
Drug Margin
E&M
Infusions
Non-E&M
Care Mgt
SAVINGS
ER/Admissions
Other
Services
Testing
Avoidable $
Drugs
Drug Margin
Care Mgt
E&M
Infusions
Non-E&M
Payment for care management,
triage, and rapid response to
complications leads to lower
use of Emergency Rooms and
fewer hospital admissions
Pay to Support Value-Based Treatment
Cancer Care
Spending
Per Patient
$45,000
$40,000
ER/Hospital
Admissions
$35,000
Other
Services
$30,000
Testing
$25,000
Avoidable $
$20,000
$15,000
Drugs
$10,000
$5,000
$0
Drug Margin
E&M
Infusions
Non-E&M
Care Mgt
SAVINGS
ER/Admissions
SAVINGS
ER/Admissions
Other
Services
Testing
Avoidable $
Drugs
Drug Margin
Care Mgt
E&M
Infusions
Non-E&M
Other
Services
Testing
Drugs
Drug Margin
Non-FFS Svcs
E&M
Infusions
Payment for
services delivered
by non-physicians
and for non-faceto-face services
improves drug and
test utilization and
improves end of life
care
PCOP Episode of Chemotherapy (IV or Oral)
Care
Mgt
5
6
TREATMENT MONTHS
7
8
9
10 11
EM
EM
CM
EM CM
CM
EM CM
4
CM
3
E&M CM
2
E&M
1
E&M CM
E&M
0
PATIENTCENTERED
ONCOLOGY
PAYMENT
(PCOP)
Care Management Payments
During Active Monitoring Months
Up to 6 Months After End of
Treatment
Infusion
Care
Mgt
E&M
Infusion
Care
Mgt
E&M
$0
E&M
$200
E&M
$400
Monthly
Care Management Payments
During Treatment Months
Infusion
$600
Infusion
$800
New Patient
$1,000
Infusion
Care
Mgt
$1,200
Care
Mgt
Additional
One-Time Payment
for Each New Patient
12 13 14 15
ACTIVE MONITORING
Must Follow Appropriate Use Criteria
100%
80%
Min%
HIGH
LOW
Rate of
Adherence to
Appropriate
Use Criteria
Rate of
Adherence to
Appropriate
Use Criteria
$
Care Mgt
Payment
Care Mgt
New Patient
Payment
New Patient
Infusion
Infusion
E&M
E&M
Bonus If ED/Hospital Use Better Than Target
GOOD
Target Rate
Achieve
Target Rate
for ED Visits
and Hospital
Admits
HIGH
High Rate
of ED Visits
and Hospital
Admissions
LOW
Low Rate of
ED Visits and
Admits
BONUS
$
Care Mgt
Payment
Care Mgt
Payment
Care Mgt
New Patient
Payment
New Patient
New Patient
Payment
Infusion
Infusion
Infusion
E&M
E&M
E&M
Illustrative PCOP Increased Practice
Resources (Medicare 2012 Fee Model
~$2,100/patient)
Care
Mgt
5
6
TREATMENT MONTHS
7
8
9
10 11
EM
EM
CM
EM CM
CM
EM CM
4
CM
3
E&M CM
2
E&M
1
E&M CM
E&M
0
PATIENTCENTERED
ONCOLOGY
PAYMENT
(PCOP)
$50 Care Management Payments
During Active Monitoring Months
Up to 6 Months After End of
Treatment
Infusion
Care
Mgt
E&M
Infusion
Care
Mgt
E&M
$0
E&M
$200
E&M
$400
$200 Monthly
Care Management Payments
During Treatment Months
Infusion
$600
Infusion
$800
New Patient
$1,000
Infusion
Care
Mgt
$1,200
Care
Mgt
Additional $750
One-Time Payment
for Each New Patient
12 13 14 15
ACTIVE MONITORING
Illustrative Analysis: Savings Will More
Than Offset New Payments
Current
FFS
Payment
$45,000
$40,000
$35,000
$30,000
$25,000
ER/Hospital
Admissions
Other
Services
Testing
Other
Services
Testing
Avoidable $
SAVINGS
ER/Admissions
Other
Services
Testing
Avoidable $
$20,000
$15,000
ER/Hospital
Admissions
PatientCentered
Oncology
Payment
Drugs
Drugs
$0
E&M
Infusions
Non-E&M
Care Mgt
30% reduction
in ER visits &
hospital admits
5-7% reduction
in spending
on drugs & tests
Drugs
$10,000
$5,000
> 4% reduction
in total
spending
PCOP Pmts
PCOP Pmts
E&M
Infusions
E&M
Infusions
50% increase
in payments
to oncology
practices
Illustrative Analysis Shows Large Potential
Net Savings (2012 Medicare)
www.asco.org/paymentreform
Payments for Patients on Clinical Trials
PATIENTCENTERED
ONCOLOGY
PAYMENT
(PCOP)
Trial
Care
Mgt
5
6
TREATMENT MONTHS
7
8
9
10 11
EM
EM
CM Trial
EM CM Trial
CM Trial
EM CM Trial
4
CM Trial
3
E&M CM Trial
2
E&M CM Trial
Trial
Care
Mgt
E&M
1
Infusion
Trial
Care
Mgt
E&M
0
E&M
Trial
Care
Mgt
Infusion
Trial
E&M
$0
E&M
$200
E&M
$400
Infusion
$600
Infusion
$800
New Patient
$1,000
Infusion
$1,200
Care
Mgt
Monthly Payments
For Patients in (Unfunded) Clinical Trials
12 13 14 15
ACTIVE MONITORING
A Continuum for Practice
Transformation
OPTION #3
OPTION #2
OPTION #1
Implementation Strategy
•
•
•
•
•
•
•
•
•
Gain input and support from ASCO Members
Gain support from consumer advocacy groups
Gain support from purchasers/payers
Gain support from Congress/Administration/policy
community
Create and/or aquire tools to help practices implement new
payment models
Refine data analysis supporting the business case for
PCOP
Refine PCOP models based on input and analysis
Develop additional guidelines and value-based measures
Initiate discussions of multi-specialty coordination in
oncology
PCOP Current Status
• Collecting/analyzing clinical/administrative data to better
define payment amounts, risk corridors, unpaid services
Data Analysis Capability (including PHI)
Up dating Maine data
• Pursuing pilots
– With multiple practices, diverse settings
– Outreach to payers (CMS and commercial)
• Pursuing standard performance measures/programs
–
–
–
–
Clinical performance (overuse, underuse)
Care processes/management (hospitalizations, ER visits)
Practice Transformation Tools
Exploring expanding QOPI with eventual integration with
CancerLinQ
Barriers to Pilot
• Payer Reluctance
• Integrated health system CFO
• CMS (Oncology Care Model)
– Designate PCOP as APM for MACRA?
• Acquiring payer data for modeling (legal)
• Complexity and risk of bundled payment
• Contract negotiation
PCOP Model Opportunities
• Integration of oncology specialty with ACO’s
• Expansion beyond episode of therapy
– Survivorship (intermediate and long term post
therapy care and monitoring)
– Multidisciplinary integration (i.e. surgery and RT)
• Medical Oncology as “team leader”
(1) QOPI Needs to Serve as the Underpinning
of any Reimbursement System
• QOPI (Quality Oncology Practice Initiative)
• Only nationally accepted oncology quality program
• Started in 2005 by oncologists to measure outcomes that
are clinically meaningful
• Two status levels: participation (fulfill 2 measures) and
certification (5 measures)
• Currently, about 600 practices are certified nationwide
FOR MORE INFORMATION AND
TO EXPLORE IMPLEMENTATION
Stephen Grubbs, MD
Senior Director of Clinical Affairs
American Society of Clinical Oncology
[email protected]
Walter E. Birch
Director, Practice Management
American Society of Clinical Oncology
[email protected]
www.asco.org/paymentreform
ASCO’s Clinical Affairs Department
Helping practices survive and thrive…today AND in the future
• Stephen S. Grubbs, MD, Senior Director Clinical
Affairs
• Hands on help for practices
– Practice efficiency; staffing models, workflow; quality
reporting/QI projects; learning networks
• Information and analysis
– Practice trends; economic analysis; performance
measurement; payment reform
• Practice priorities and programs to be driven by
you
PAYMENT MODEL
IMPLEMENTATION AND THE
ONCOLOGY MEDICAL HOME
What we have learned and
preparing for the future
Alternative Payment Models for
FFS and Buy and Bill
• Gordon Kuntz, Michigan, multipractice,
community OPCMH demonstration project
– Reduced costs of unnecessary ED visits and
hospitalizations
• Suggested community oncology practices
will embrace transformation to a patientcentered model if we have properly aligned
incentives and administrative assistance
Kuntz, JOP, 2014, 10:294-297
United Healthcare “Episodes”
Payment Model
1., doi: JOP
Journal of Oncology Practice Publish Ahead of Print, published on July 8, 2014 as doi:10.1200/JOP.2014.001488
80
Cancer Therapy Episode Payment Program Strategy
United Healthcare launched an episode payment pilot in 2009
focused on oncology services
Rewards physicians for improved
quality and reduction in total cost
of cancer
Separates oncologist’s income
from drug sales
Builds a learning system to
identify best practices for cost
control and quality
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
81
Alternative Payment Models for
FFS and Buy and Bill
• Lee Newcomer, M.D., UnitedHealthcare
– 5 community oncology practices
– Explored a gain sharing, episodes of care chemo
management + sharing best-of-practice quality
benchmarks
– Resulted in a 34% savings compared to matched
controls under FFS
• Aggressive management of chemo episodes
removing ASP incentives did not result in savings
• Required intensive patient management much like
an OMH structure to actualize cost savings.
– Traditional FFS does not cover management costs,
however, our achieved gain sharing did cover costs
Newcomer, JOP, 2014, 10:322-326
Discussion
• Primary objective of decreasing total
medical costs was achieve
–
–
–
–
–
–
Better global management of patients
Kept patients out of ER/Hospital
Data sharing of quality measures
Micromanaging chemo regimens had no impact
Can we scale this model?
M.D. Anderson and UnitedHealthcare bundled
payment model in Head and Neck Cancer
Aetna Shared Savings Pilot
• Incentives and risks have to be aligned among
doctors and payers and focused on patient
outcomes.
• A phased approach that supports change
• Model supports the use of clinical pathways
(evidence-based care guidelines)
• Utilizing patient-centered medical homes for
oncology programs and benchmarks
• Quality performance measurement and
information sharing
Elements of quality measures
resulting in shared savings
• ER Visits (and costs)
• Hospitalization rates (and costs)
• Chemotherapy costs
• Adherence to evidence based treatment guidelines
(including treatment exceeding lines of therapy
and documentation of off-pathways reasons)
• Cancer staging, performance status, pain
assessment
• End of life metrics (ACP documentation, hospice
enrollment, hospice length of stay)
• Patient satisfaction
Aetna Reimbursement Models
• Enhanced fee schedule for treatment plans
–
–
–
–
•
•
•
•
Treatment plan
End of treatment summary
Advanced care planning
Oral chemo therapy management
S codes for quality processes that make sense
Shared savings, compared to your market
Prior auth relief
Oncology Medical Home Aetna/Moffitt Cancer
Center
Oncology Medical Home
Concept
• Currently serious concerns about care and
management of cancer patients
– Exponentially increasing costs
– Compromises in quality of care
• Desire for potential solutions include
– Alternative Payment Models
– Evidence-based care (Pathways)
– Value-driven cancer care (Choosing Wisely)
– Innovative patient management models
Oncology APM
COME HOME
• Medical Home model, 7 practices nationwide
• Significant reductions in hospital/ED use
Community Oncology MEdical
HOME COME HOME Program
• Barbara McAneny, M.D., Innovative Oncology
Business Solutions (IOBS)
• Name of the $19.8M CMMI grant
• 7 U.S. practices
• Patients managed under OMH structure
–
–
–
–
Centralized, protocol driven triage nurses
Expanded office hours, 24/7 clinical staff access
Treatment pathway development and compliance
Laboratory/Molecular diagnostics efficiency
McAneny, J. Managed Care, 2013, SP41-42
Community Oncology MEdical
HOME COME HOME Program
• Purpose is intended to show community
oncology practices as an OMH can:
–
–
–
–
More efficiently manage patient care
Improve outcomes
Provide better patient satisfaction
Produce cost savings
• Early CMS data shows a reduction in ER visits,
hospital admissions, and total costs of care
• Directions of COME HOME
Oncology Medical Home (OMH)
• Commission on Cancer (CoC) Accreditation
Pilot Program
Participating Practices
•
•
•
•
•
•
•
•
Austin Cancer Centers, Austin, TX
Center for Cancer and Blood Disorders, Fort Worth, TX
Dayton Physicians Network, Dayton, OH
New England Cancer Specialists, Portland, ME
New Mexico Cancer Center, Albuquerque, NM
Northwest Georgia Oncology Centers. Marrietta, GA
Space Coast Cancer Center, Titusville, FL
Hematology Oncology Associates of Central New York,
Syracuse, NY
• Oncology Hematology Associates of Springfield,
Springfield, MO
• Oncology Hematology Care, Cincinnati, OH
What is an Oncology Medical
Home?
• A Medical Home, also referred as a PatientCentered Medical Home (PCMH), is a team
based healthcare delivery model led by a
physician. The model provides
comprehensive and continuous medical care
to patients with the goal of obtaining
maximized health outcomes
Medical Home Purpose
•
•
•
•
Improved access to healthcare
Increased patient satisfaction
Improved medical outcomes
Efficient delivery of care and reduced costs
Eligibility Requirements
• ER1 – The Oncology Medical Home (OMH) Practice
leadership, including administrators and physicians,
support the OMH concept, and adopt policies and
procedures to achieve OMH accreditation
• ER2 – The OMH practice utilizes a certified
Electronic Health Record as defined by the Centers
for Medicare and Medicaid Services (CMS).
• ER3 – The OMH practice submits applicable data
annually to verify compliance with mandatory
performance measures
Implementing OMH Model
•
•
•
•
•
•
•
•
•
Dedicated triage nurses, centralized phones
Expanded hours
Navigators/Nurse educators
Coordinated emergency/hospital management
Treatment pathways
Patient portal and communication
Clinical trials support
Psychosocial distress evaluation
Survivorship clinic
Key Points
• As we look for FFS alternatives, several
performance based payment options exist
with ranges of financial risk, reward, and
accountability
• Practices need to consider contractually
negotiate with payers to start with OMH
quality methods and payment models that fit
their practice environment and market
Key Points
• The OMH practice infrastructure required to
create cost saving is not covered under
traditional FFS
• Rewards for OMH performance should be
based on a small number of meaningful
quality performance measures
Key Points
• To cover practice costs of an OMH,
practices will need to enter payer contracts
that recognize the value of all services
provided beyond the patient/physician
encounter
• The ASCO Patient-Centered Oncology
Payment (PCOP) is designed to do this
Thoughts
• The Oncology Medical Home concept has
now been show to be a viable foundation to
carry out quality-driven, cost-effective
comprehensive management of cancer
patients
• Much of the value gained from the OMH
infrastructures comes through refinement of
day-to-day patient care processes resulting
in superior outcomes
Thoughts
• For oncology practices to remain viable,
successful management of the financial
risks associated with APMs can be lessened
by incorporating OMH processes
• Without appropriate payer support, further
attrition of community-based practices can
be anticipated resulting in escalating costs
and decline in value.
Clinical Pathways in Oncology
Clinical Pathways Task Force
• Background
– Increasingly used in oncology to reduce variation,
control cost
– Concerns regarding impact on access, quality of care
– SAC brought concerns to ASCO Board, January 2015
– Board charged special task force to explore
• Task Force Charge:
– Assess current environment
– Develop recommendations on ASCO role
103
Task Force Members
Member
Robin Zon (Chair)
Linda Bosserman
James Frame
Michael Neuss
Ray Page
Role
Clinical Practice
Board of Directors
State Affiliate Council
Quality
State Affiliate Council
Environmental Analysis
• Inventory of current pathway programs
• Extent of payer use
• Extent of collaboration between pathway vendors and payers
• Description of pathway use by oncology providers
• Role of specialty benefits management organizations
ASCO Provider Survey
Key Findings
• Pathways should have the ability to
– Link documentation to EMR
– Create a patient tool
– Integrate quality measures
• Pathways should be are accredited by a nationallyrecognized clinical organization
• Pathways for all treatment modalities
Key Findings
• Pathways can promote high quality care but must be
implemented responsibly to do so.
• Pathways are here to stay but will change over time
• No system exists to ensure pathway integrity or quality, or to
mitigate negative effects of proliferation.
• What is needed:
– A set of criteria is needed to ensure the quality of pathways coming to
market today
– A national pathways program
– A set of pathways that cover the full range of care, not just drugs
• ASCO will need to engage in pathways in order to be relevant.
• ASCO brings trust and credibility, and the ability to serve as an
“honest” broker in the pathways space.
107
Guiding Principles for Pathway
Development
• Practicing oncologists should play a central role
• Robust and transparent process
• Clearly defined parameters for adherence
• Established mechanisms to guide provider-payer
communication when off-pathway or on-pathway
modification decisions are being considered
End to End Pathways Concept
Today
• Narrowly defined by
disease and treatment
regimens
Tomorrow
• From diagnosis through
surveillance
• Clinical process measures
• Outcome measures
• No evaluation of pathway
effectiveness
• Evaluate pathway using
clinical and administrative
data
109
Pathways and New
Reimbursement Methodologies
Pathways could help physicians fulfill quality
requirements under MACRA and other new payment
paradigms.
• MIPS incentivizes quality over volume
–
–
–
–
Meaningful Use
Clinical Practice Improvement Activity
PQRS
Resource Use
• APMs aims to increase accountability for both quality and
total cost of care
– ASCO’s PCOP
– COME HOME Medical Home Project
Summary
• Administrative burdens continue to
adversely impact oncology practices
• The costs of cancer care are unsustainable
• MACRA – We now how law that will drive
how you get paid in the near future.
• Practice transformation is essential to
prepare for APMs
Summary: Components of
Comprehensive Medical Oncology
Payment Reform
1. ASCOs PCOP payment model as an APM
2. The Quality Oncology Practice Initiative (QOPI)
3. ASCO’s “Choose Wisely” benchmarks
4. ASCO deemed Oncology Treatment Pathways
5. ASCO’s Value Based Pathways
6. Care Coordination/Patient-Centered Medical
Oncology Home
7. CancerLinQ – Data mgmt/rapid learning
State Efforts Matter
• Visit with members
of Congress (home
or DC)
• Share your stories
• Supportive
letters/messages
• Participate in State
Affiliate Council
• Stay in touch!
Rep. Pete Sessions (TX) and Dr. Ray Page
Questions?