LEVERAGING TECHNOLOGY AND PATIENT ENGAGEMENT TO …

CARRIE TOMPKINS STRICKER, PHD, RN CHIEF CLINICAL OFFICER & CO-FOUNDER

CAREVIVE SYSTEMS, INC.

LEVERAGING TECHNOLOGY AND PATIENT ENGAGEMENT TO OPTIMIZE VALUE-BASED CANCER CARE:

THE CAREVIVE EXPERIENCE

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OBJECTIVES

▸  Provide a overview of value-based care delivery and reimbursement models in oncology

▸  Discuss the role of technology and patient engagement in achieving value-based cancer care

▸  Overview the development, implementation, and evaluation of Carevive products in the real world

▸  Including evolution over time in response to market drivers

▸  Share lessons learned from bridging the academia-industry interface

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BACKGROUND 1.  U.S. healthcare system is regularly criticized as being inefficient, inaccessible and

way too costly

2.  As a result, the healthcare system is undergoing a transformation from traditional “volume-based” to the notion of “value-based” care

3.  Cancer care, with high variability in terms of both outcomes and cost, is of particular interest as a candidate for transformation

4.  This transformation is being catalyzed in large part by the Affordable Care Act (“ACA”) and it’s various alternative payment model (APM) initiatives

5.  CMMI’s new Oncology Care Model (OCM) is one such APM initiative designed to financially incentivize oncology providers to engage in the transformation [innovation.cms.gov/initiatives/oncology-care]

6.  REFORM IS HERE TO STAY. Cost of healthcare is unsustainable. 17.5% of GDP in 2015 and climbing. Medicare to be insolvent by 2020. Regardless of new Administration, Congress has weighed in: volume ! value (MACRA)

3 Courtesy of Ron Barkley, MS, JD - rbarkley@ccbdgroup.com

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WHY DOES HEALTH CARE DELIVERY AND REIMBURSEMENT NEED TO CHANGE?

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THE EVOLUTION OF CANCER CARE REIMBURSEMENT The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed in 2016, effectively repealing the sustainable growth rate (SGR) and introducing comprehensive changes in how Medicare pays physicians for services.

As the policies passed in MACRA, new Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs) will profoundly impact reimbursement and care delivery for oncology practices throughout the United States.

The first CMS-sponsored Alternative Payment Model, the Oncology Care Model (OCM), was announced in April 2016

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CHRONOLOGY OF ONCOLOGY ALTERNATIVE PAYMENT

2009 Drug Pathways Compliance

Payor waives pre-auth, pays > for generics if

drug pathways compliance. CareFirst

BC , Highmark BC, Michigan BC

2009-201

2

United H/C Episodes Model

Replaces % drug mark-up with pre-set drug margin payment. Findings published 2014: drug costs not reduced, but overall “spend” down by 11% annual

2010 Oncology Medical Home (OMH)

John Sprandio, MD, Drexel Hill, PA. Applies to NCQA for PCMH certification and originates the OPCMH model

2010 -

2012

US Oncology - Innovent Model

Aetna + Texas Oncology. Pro-active

care management reduces ER and

inpatient costs. 12% annual by year 2

2011 Priority Health OMH

Priority Health Plan and Michigan oncologists.

$550 per patient reduction in ER and

hospitalization costs May 2012

Oncology ACO

Baptist Health + Advanced Med

Specialties + Florida Blue. Add Hospital to

OMH = Onc ACO. Shared savings

May 2014

Anthem Cancer Care Quality

$350 per treatment patient per month for

pathway compliance + care coordination

7

Chronology)of)Oncology)Alternative)Payment

2009 Drug)Pathways)Compliance))

Payor)waives)pre=auth,)pays)>)for)generics)if)drug)pathways)compliance.))CareFirst)BC),)Highmark)BC,)Michigan)BC)

2009=2012 United)H/CEpisodes)Model)))

Replaces)%)drug)mark=up)with)pre=set)drug)margin)payment.)Findings)published)2014:)drug)costs)not)reduced,)but)overall)“spend”)down)by)11%)annual)

2010 Oncology)Medical)Home))(OMH)

John Sprandio,)MD,)Drexel)Hill,)PA.)Applies)to)NCQA)for)PCMH)certification)and)originates)the)OPCMH)model))

2010)= 2012 US)Oncology =Innovent Model)

Aetna +)Texas)Oncology.)Pro=active)care)management))reduces)ER)and)inpatient)costs.)12%)annual)by)year)2)

2011 Priority)Health)OMH

Priority Health)Plan)and)Michigan)oncologists.)$550)per)patient)reduction)in)ER)and)hospitalization)costs))

May)2012 Oncology)ACO Baptist Health)+)Advanced)Med)Specialties)+)Florida)Blue.)Add)Hospital)to)OMH)=)Onc ACO.)Shared)savings)

May)2014) Anthem)Cancer)Care)Quality

$350)per)treatment)patient)per)month)for)pathway)compliance))+)care)coordination))

4

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CHRONOLOGY OF ONCOLOGY ALTERNATIVE PAYMENT

Aug 201

4

OCM Design Paper

OCM Model to improve quality, reduce costs for

Medicare FFS beneficiaries

undergoing chemo Oct 2014

Aetna Oncology Medical Home Program

Care coordination activities. Enhanced

generic drug payment + shared

savings

Oct 2014

Horizon BC NJ Episodes of Care

Horizon BC – RCCA retrospective

bundled pricing for breast cancer

treatment Dec 2014

MD Anderson – UHC

Bundled pricing: head & neck cancers. All care for one year.

May add lung, prostate

Apr 2015

Medicare Access & CHIP Reauthorization Act

Congress weighs in: MACRA repeals SGR. Mandates merit-based pay (MIPS) or advanced APMs. OCM 2-sided risk qualifies as an APM

July 2015

Comprehensive Care for Joint Replacement (CJR)

MANDATORY hip & knee bundled pricing in 75 markets – mandatory as harbinger of future?

July 2016

OCM Launch Date

195 OCM Participants

scrambling. $160 PBPM for 6-mo

Episode + performance-based

pay (PBP)

8

Chronology)of)Oncology)Alternative)Payment

Aug)2014 OCM)Design)Paper OCM)Model)to)improve)quality,)reduce)costs)for)

Medicare)FFS)beneficiaries)undergoing)chemo)

Oct)2014) Aetna)Oncology Medical)

Home)Program)

Care)coordination)activities.)Enhanced generic)

drug)payment)+)shared)savings)

Oct)2014 Horizon)BC)NJ)Episodes)of)

Care)

Horizon)BC)– RCCA)retrospective bundled pricing)

for)breast)cancer)treatment)

Dec 2014 MD)Anderson)– UHC Bundled)pricing: head)&)neck)cancers.)All care)for)

one)year.)May)add)lung,)prostate

Apr 2015 Medicare)Access)&)CHIP)

Reauthorization)Act

Congress)weighs)in:)MACRA)repeals)SGR.)

Mandates)meritVbased)pay)(MIPS))or)advanced)

APMs.)OCM)2Vsided)risk)qualifies)as)an)APM

July)2015 Comprehensive)Care)for)

Joint)Replacement)(CJR))

MANDATORY)hip)&)knee)bundled)pricing)in)75)

markets)– mandatory)as)harbinger)of)future?)

July 2016 OCM)Launch)Date)))) 195)OCM)Participants)scrambling.)$160)PBPM)for)

6Vmo)Episode)+ performanceVbased pay)(PBP)))

5

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Shared Savings

1 - sided risk

FAMILY TREE OF ONCOLOGY ALTERNATIVE PAYMENT

Pay for

Enhanced

Services

Pay for

Pathways

Compliance

©CCBD Group. 2016

Volume-Based

Fee-for-Service

Shared Savings

2 - sided risk

Bundled Price

Episode of Care

Oncology

Medical Home*

Bundled Price

Specific Treatment

?

*OMH Key Features: pathways compliance; pro-active care management; end-of-life planning (NCQA ‘10; Aetna ‘14)

Oncology Care

Model (OCM)

MACRA

Increasing

Financial Risk

Capitation

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CMS’ ONCOLOGY CARE MODEL (OCM)

▸  Goal: incentivize providers to improve care and reduce spending for Medicare beneficiaries with cancer who receive chemotherapy

▸  Eligibility: physician practices that provide care for oncology patients undergoing chemotherapy for cancer 

▸  Includes both independent medical practices and hospital-affiliated practices

▸  Term: 5-year program commenced July 1, 2016 (“Start Date”)

▸  Participation: 195 participating practices and 17 participating health plans

▸  2018 will bring new participants

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OCM BASICS

▸  Objective: reduce the total cost of care for an OCM Beneficiary during a 6-month “Episode” to an amount below a “Target Price”

▸  1 and 2-sided risk arrangements* ▸  1-sided risk to June 30, 2018; option to assume 2-sided risk thereafter ▸  Deduction from “Benchmark Price” to determine Target Price: 4.0% 1-sided

risk; 2.75% 2-sided risk

▸  Payment: Traditional FFS plus PBPM plus performance payment (based on savings vs. Target Price).

▸  Practice transformation via 6 Practice Redesign Activities

▸  Metric reporting via 12 key performance indicators (KPI’s)

▸  Monitoring: Lots of monitoring by CMS/contractors, including on-site inspections *1 sided: practice must qualify for PBP by the end of the third performance year; 2-sided risk model qualifies as an APM under MACRA

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WHAT DRIVERS OF COST IN CANCER CARE DOES OCM TARGET?

Cost of chemo/cancer treatments

Poor end of life care Unnecessary hospitalizations and ED visits

SUPPORTIVE CARE FOCUS

THE ONCOLOGY CARE MODEL: 10 WAYS CAREVIVE CAN ASSIST

CANCER CENTERS MEET THE REQUIREMENTS

OCM METRICS

TREATMENT PLANNING FOCUS

THE ONCOLOGY CARE MODEL: 10 WAYS CAREVIVE CAN ASSIST

CANCER CENTERS MEET THE REQUIREMENTS

OCM METRICS

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WHAT DRIVERS OF COST IN CANCER CARE DOES OCM TARGET?

Cost of chemo/cancer treatments

Poor end of life care Unnecessary hospitalizations and ED visits

… Why??

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DATA ON SOURCES OF COST SAVINGS

Source % Cost Reduction

Drug pathways compliance 1.0% to 3.0%

Avoidable ER utilization 0.6% to 1.1%

Avoidable hospital admissions 4.0% to 7.0%

Diagnostics (imaging, lab) 0.2% to 0.5%

End-of-life care management 0.9% to 1.9%

Total potential savings 6.7% to 13.5%

(1) John D. Sprandio, MD, Consultants in Medical Oncology & Hematology. Oncology Patient Centered Medical Home ® Analysis of OPCMH savings conducted by third party actuary 2010. (2) How Oncologists are Bending the Cost Curve. Oncology Times. January 10, 2013. (3) Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model. Newcomer et. Al. Journal Oncology Practice. July 8, 2014.

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Significantly lowered cost in the case group vs. the control group

No change in overall survival between the study groups

Study: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting”. Journal of Oncology Practice (ASCO Peer Reviewed Journal), 1/19/2010

1. DRUG COSTS: ADHERING TO EVIDENCE BASED GUIDELINES DECREASE COST WITHOUT NEGATIVELY IMPACTING TREATMENT EFFICACY Purpose: Evaluate the cost effectiveness of evidence-based treatment pathways for NSCLC patients

Conclusion: Results of this study suggest that treating patients according to evidence-based guidelines is a cost-effective strategy for delivering care to those with NSCLC

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DATA ON SOURCES OF COST SAVINGS

Source % Cost Reduction

Drug pathways compliance 1.0% to 3.0%

Avoidable ER utilization 0.6% to 1.1%

Avoidable hospital admissions 4.0% to 7.0%

Diagnostics (imaging, lab) 0.2% to 0.5%

End-of-life care management 0.9% to 1.9%

Total potential savings 6.7% to 13.5%

(1) John D. Sprandio, MD, Consultants in Medical Oncology & Hematology. Oncology Patient Centered Medical Home ® Analysis of OPCMH savings conducted by third party actuary 2010. (2) How Oncologists are Bending the Cost Curve. Oncology Times. January 10, 2013. (3) Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model. Newcomer et. Al. Journal Oncology Practice. July 8, 2014.

About 2/3 of

the savings comes

from avoidable

hospital events.

In a BWH series, 21-28% of cancer patient ED visits were deemed avoidable (compared to 12% of general population)

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WHAT STRATEGIES REDUCE AVOIDABLE HOSPITAL EVENTS?

Symptom'monitoring'with'pa/ent1reported'outcomes'during'rou/ne'cancer'treatment:'

A'randomized'controlled'trial!

Ethan!Basch,!Allison!Deal,!Mark!Kris,!Howard!Scher,!Clifford!Hudis,!Paul!Sabba>ni,!Lauren!Rogak,!Antonia!BenneB,!Amylou!Dueck,!Thomas!Atkinson,!Joanne!Chou,!Dorothy!Dulko,!Laura!Sit,!Allison!

Barz,!Paul!Novotny,!Jeff!Sloan,!Deborah!Schrag!!!

October!2015!

RCT!Design!

21

Patients Receiving Chemotherapy for Solid Tumors at Sloan Kettering

Self-report 12 common symptoms at/between visits ! Email alerts to nurses ! Printed reports at visits

Usual care

R A N D O M I Z E

Outcomes -  ER visits -  Hospitalization -  Duration of

chemotherapy -  Quality-adjusted

survival -  Overall survival -  QOL at 6 months

(EuroQoL EQ-5D)

Follow for up to 1 year or until death or discontinuation of chemotherapy/hospice

N=766

Cumula>ve!Incidence!of!Hospital!Events!

22!

All patients

0 6 12 18 24 30 36

20

40

60

Months Since Enrollment

Patie

nts

Vis

iting

ER

(%) Usual care

STAR

p=0.02

Computer−experienced

0 6 12 18 24 30 36

20

40

60

Months Since Enrollment

Patie

nts

Vis

iting

ER

(%)

Usual care

STAR

p=0.16

Computer−inexperienced

0 6 12 18 24 30 36

20

40

60

Months Since Enrollment

Patie

nts

Vis

iting

ER

(%)

Usual care

STAR

p=0.02

Cumulative IncidenceAll patients

0 6 12 18 24 30 36

20

40

60

Months Since Enrollment

Patie

nts

Hos

pita

lized

(%)

Usual care

STAR

p=0.08

Computer−experienced

0 6 12 18 24 30 36

20

40

60

Months Since Enrollment

Patie

nts

Hos

pita

lized

(%)

Usual care

STAR

p=0.75

Computer−inexperienced

0 6 12 18 24 30 36

20

40

60

Months Since Enrollment

Patie

nts

Hos

pita

lized

(%)

Usual care

STAR

p=0.003

Cumulative IncidenceEmergency Room Visits 41% vs. 34% of Patients

P=0.02

Hospitalization 49% vs. 45% of Patients

P=0.08

Time receiving chemotherapy: mean 6.3 vs. 8.2 months (p=0.002)

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COST SAVINGS

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WHAT’S STOPPING US FROM TRANSLATING THESE IMPROVEMENTS IN CARE AND OUTCOMES?

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WHY AREN’T WE ROUTINELY INCORPORATING THE PATIENT VOICE?

JAMA, 2015

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And incorporating palliative care across the cancer care continuum?

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CAN TECHNOLOGY HELP?

Dr. Hesse, 6/17/16: “Automate appropriately so that clinicians can do their

work more effectively”

Can we create disruptive technology that is not simply DISRUPTIVE!?!

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CAREVIVE MISSION Bend the curves in cancer care

HOSPITAL ADMISSIONS/RE-ADMISSIONS COSTS OF CARE

# OF SURVIVORS TREATMENT ADHERENCE

ED VISITS

PATIENT QUALITY OF LIFE

CLINICAL OUTCOMES

… through technology, process, and clinical expertise

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RAPID LEARNING…..

▸  Moving towards a Rapid Learning System in Cancer Care

Abernathy AP et al. J Clin Oncol. 2010 Sep 20;28(27):4268-74

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THE CAREVIVE APPROACH

Carevive Systems develops the tools and processes to succeed in value-based models while driving patient-centered care

•  Our tools help optimize the balance between care team engagement and patient self-management

•  Our platform collects longitudinal data on the cancer patient experience to:

• drive better, more efficient care delivery, • improve clinical outcomes at lower costs, and

• enable analysis and reporting of the same!

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I can afford my co-pay for the treatment

recomended

Diagnosis •  Treatment Plans &

Navigation •  Distress Screening

Active Treatment •  Distress Screening &

Navigation •  Symptom Management

Survivorship •  Distress Screening •  Survivorship Care Plans &

Navigation

My treatment plan is aligned with my goals. I am high-risk but will follow the surveillance plan.

I know what to report & who to call I am aware of my

risks and follow up recommendations.

$$

Navigator Doctor Financial Social Chemo Rehab Radiation Nurse Counselor Worker RN Therapist Nurse Practitioner PCP

THE CAREVIVE MODEL

Coordinating Care

Incorporating the patient

voice

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HOW DID WE GET HERE? ▸  Initially, CoC accreditation was the market driver

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SURVIVORSHIP CARE DELIVERY: WHERE MY JOURNEY FROM ACADEMIA TO INDUSTRY BEGAN

Phase I: N = 13 cancer centers delivering SCPs

Stricker, C.T., Jacobs, L.A., Risendal, B….. & Palmer, SC. Journal of Cancer Survivorship 5(4): 358-370.

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PHASE 1 LIVESTRONG STUDY- PROCESS: HIGH RESOURCE BURDEN, LOW REACH

SURVIVORSHIP CARE PLANS

5(4): 358-370

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SURVIVORSHIP CARE PLANS (SCPS): “HELPFUL, BUT NOT GOOD ENOUGH”

▸ Key patient perspectives on SCPs delivered in LIVESTRONG network study ▸  Information helpful; “wish I had received it sooner”

▸  Personalization needed

▸  So much information is overwhelming

▸  “What is relevant to me?” And my concerns and symptoms?

▸  Need for more actionable information

▸  What to report, to whom

▸  How to self-manage & access relevant resources

Unpublished data; Stricker, Jacobs, Palmer et al

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TAKING A “SIMPLE IDEA” TO THE INDUSTRY SIDE

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THE “SIMPLE” IDEA

1 2

3 4

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THE “NOT SO SIMPLE” EXECUTION

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RULES ENGINE TECHNOLOGY ENABLES AUTOMATED TAILORING

▸  Carevive rules engine technology convert knowledge into a code base that is used for reasoning (i.e., we process data from a knowledge base to infer conclusions)

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ONCOLOGY EXPERT ADVISORS MAINTAIN CONTENT

Nearly 1,000 oncology experts across the United States develop tools, maintain content, and

perform research using the Carevive platform.

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CAREVIVE SYSTEMS MAINTAINS EXTENSIVE CONTENT

Professional Society Guidelines Advocacy Group Education & Resources

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HOW ARE CENTERS USING CAREVIVE?

▸  …. And what process and outcome improvements is this generating?

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HARTFORD HEALTHCARE STANDARDIZED SURVIVORSHIP CARE ACROSS MULTIPLE SITES

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…. AND HHC’S PATIENT-DRIVEN CARE PLANS IMPROVE LIKELIHOOD OF ADOPTING RECOMMENDED CARE

Web Link: https://www.carevive.com/poster-presentation-recall-uptake-survivorship-care-plan-recommendations-survonc16/

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NEXT …. OCM DROVE CARE PLANNING TO THE BEGINNING OF THE CANCER CARE CONTINUUM

SURVIVORSHIP CARE PLANS

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1! Patient information (e.g., name, date of birth, medication list, and allergies) !

2! Diagnosis, including specific tissue information, relevant biomarkers, and stage !

3! Prognosis !

4! Treatment goals (curative, life-prolonging, symptom control, palliative care) !

5! Initial plan for treatment (chemotherapy, surgery and radiation therapy)!

6! Expected response to treatment !

7! Treatment benefits/harms and management strategies!

8! Information on quality of life and a patient’s likely experience with treatment !

9! Who will take responsibility for specific aspects of a patient’s care !

10! Advance care plans!

11! Estimated total and out-of-pocket costs of cancer treatment !

12!

A plan for addressing a patient’s psychosocial health needs, including psychological, vocational, disability, legal, or financial concerns and their management !

13! Survivorship plan, including a summary of treatment and information on recommended follow- up activities and surveillance, risk reduction and health promotion activities!

OCM REQUIRES CARE PLANS* CONTAINING THE IOM 13 COMPONENTS

'

*OCM requires delivery/documentation of IOM Care Management plan once every 6 month care episode

carevive.com Carevive care plans suggest referrals and follow up actions tailored to the

individual patient’s treatment plan and risk factors

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CARE MANAGEMENT PLANS IMPROVE ADHERENCE TO QUALITY METRICS

To date, 745 treatment care plans have been delivered as part of this project at UAB and network affiliates, plus Atlanticare Cancer Institute (NJ)

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EARLY EFFORTS TO IMPLEMENT E-PRO DRIVEN SYMPTOM CARE PLANS DURING TREATMENT….

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…. MET WITH INITIAL CLINICAL ADOPTION

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… AND HIGH PATIENT SATISFACTION AND PERCEIVED PATIENT-CENTERED CARE

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…BUT WORKFLOW ENHANCEMENTS WERE REQUIRED TO ENSURE SUSTAINABILITY AND FOCUS

Mobile symptom reporting

Clinician dashboards

Clinician alerting

In q3-4 2016, 3137 surveys at Seidman alone

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… AND REQUIRED DISENTANGLING CDS & PATIENT SELF-MANAGEMENT, WHILE STILL RETAINING COMPLEMENTARITY

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WILL THESE NEW TOOLS AND PROCESSES RESULT IN ENHANCED OUTCOMES?

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OR ARE FURTHER ENHANCEMENTS NEEDED, INCLUDING RISK STRATIFICATION?

Patient-Reported Outcomes (e.g., psychosocial physical, functional)

Socioeconomic factors

Treatment (e.g., concomitant chemo/rad)

Diagnosis (e.g., metastatic disease)

Cancer center customers apply interventions in the Carevive platform to monitor higher-risk populations (e.g., increased pt. assessments, mobile access, care plan modifications, increased navigation touchpoint

Geographic factors

Other clinical variables (e.g., co-morbidities)

CAREVIVE DYNAMICALLY CATEGORIZES PATIENTS INTO RISK CATEGORIES FOR TREATMENT ADHERENCE, ED VISITS,

ADMISSIONS & 30-DAY READMISSIONSWITH EACH PATIENT SELF-ASSESSMENT

TIME

!! Moderate Risk

High Risk

Low Risk Moderate Risk

Moderate to High Risk

High Risk

Moderate to High Risk

High Risk High Risk

Low to Moderate Risk

High Risk High Risk High to Very High Risk

High Risk Moderate Risk

Low to Moderate Risk

Very High to High Risk

High Risk to Moderate

Moderate Risk

Low Risk High Risk

Low to Moderate Risk

Low Risk Low Risk Low Risk

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COMING FULL CIRCLE

▸  Moving towards a Rapid Learning System in Cancer Care

Abernathy AP et al. J Clin Oncol. 2010 Sep 20;28(27):4268-74

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CAREVIVE IS COMMITED TO IMPLEMENTATION SCIENCE & ACADEMIC-INDUSTRY PARTNERSHIPS

IN 2015-2016, WE PRESENTED >20 POSTER AND ORAL PRESENTATIONS WITH ACADEMIC AND COMMUNITY INSTITUTIONAL PARTNERS

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ONGOING AND FUTURE RESEARCH COLLABORATIONS

▸  Mobile ePRO-driven, interactive survivorship care plans (Salz/Baxis)

▸  Tablet-based mCGA frailty screening (Hurria/Mohile/Wildes)

▸  Managing toxicities of & adherence to targeted therapies in RCC (Fung)

▸  Risk stratification for exercise referrals in cancer survivors (Schmitz)

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HOW MIGHT WE WORK TOGETHER TO LEVERAGE THE ACADEMIC-INDUSTRY INTERFACE?