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Oncology Roundtable
2019 Oncology State of the UnionConfronting new financial pressures
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP2
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
3
A sign of the times
Utah health plan for state employees starts pharmacy tourism to Tijuana
Source Alberty E ldquoTo fight high drug prices Utah will pay for public employees to go fill prescriptions in Mexicordquo The Salt Lake Tribune October 29 2018 httpswwwsltribcomnews20181028fight-high-drug-prices Oncology Roundtable interviews and analysis
To fight high drug
prices Utah will pay for public employees to go fill prescriptions
in Mexico
The Salt Lake Tribune
October 28 2018
PEHP pharmacy tourism option
bull Covers 160000 public employees
and their families
bull Offering plane tickets to San
Diego transportation to Tijuana
and $500 cash for patients who
need specific drugs
bull Drugs include those for MS
autoimmune disorders and
prostate cancer (Zytiga)
ldquoWhy wouldnrsquot we pay $300 [in transportation
costs] to go to San Diego drive across to Mexico
and save the system tens of thousands of
dollars If it can be done safely we should be all
over thatrdquo
Rep Norman Thurston R-Provo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
4
A poster child for high costs
National focus on drugs puts cancermdashfairly or unfairlymdashin the spotlight
Source Milliman ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially InsurerdPopulation Claim Data 2004-2014rdquo April 2016 httpwwwmillimancomuploadedFilesinsight2016trends -in-cancer-carepdf IQVIA ldquoGlobal Oncology Trends 2018 Innovation Expansion and Disruptionrdquo May 24 2018 httpswwwiqviacominstitutereportsglobal-oncology-trends-2018 Oncology Roundtable interviews and analysis
35
63
36
62
Medicare Commercial
Cancer Non-cancer
Growth in costs per patient
2004-2014
n=41098 Medicare cancer patients
n=129507 commercial cancer patients
ldquoThe Punishing Cost
of Cancer Carerdquo
ldquoCost of Cancer Is
Becoming Unaffordablerdquo
The New York
Times
TIME
ldquoInsurers Push to Rein in
Spending on Cancer Carerdquo
The Wall
Street Journal
Drug costs on everyonersquos radar
increase in average
cost of new cancer
drugs from 2007-2017100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
5
Exacerbated by rising demand
Utilization will increase with aging population expanding treatment options
Source Colby SL Ortman JM ldquoThe Baby Boom Cohort in the United States 2012 to 2060rdquo US Census Bureau May 2014 httpswwwcensusgovprod2014pubsp25-1141pdf Medicare Chronic Conditions Dashboard httpswwwcmsgovResearch-Statistics-Data-and-SystemsStatistics-Trends-and-ReportsDashboardChronic-Conditions-StateCC_State_Dashboardhtml httpswwwajpmonlineorgarticleS0749-3797(12)00146-8fulltext ldquoGlobal Cancer Immunotherapies Market to 2024 - Increased Uptake of Immune Checkpoint Inhibitors Driving Growth Supported by a Large Robust Pipelinerdquo Research and Markets July 2018 httpswwwresearchandmarketscomresearch9rpwcxglobal_cancerw=4 Oncology Roundtable interviews and analysis
160
178
194
2017 2022 2027
Estimated number of new cancer
cases in the US
55estimated increase in US
population over 65 years of
age from 2010 to 2030
Factors driving increased cancer volumes
33estimated increase in
obesity prevalence in the
US from 2010 to 2030
300estimated increase in
global revenue from cancer
immunotherapy market
from 2018 to 2024
Treatment
options
Lifestyle
factors
Aging
population
In millions
I
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
6
Forcing purchasers to double down on spend
Source Oncology Roundtable interviews and analysis
1 2 3
Drug costs
bull Drug pricing reform
bull 340B
reimbursement
bull Prior authorization
bull Pathways
bull Site neutrality
bull Site-of-care
policies
Site of care Provider choice
bull Network
design
bull Centers of
excellence
Three areas of focus for payers and employers to control costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
7
If you canrsquot beat lsquoemhellip
1 Drug costs
Source Sood N et al ldquoThe Flow of Money Through the Pharmaceutical Distribution Systemrdquo USC Schaeffer Center for Health Policy amp Economics June 2017 Oncology Roundtable interviews and analysis
Amazon-PillPack
Acquisition gives Amazon instant access to all 50 states where PillPack is licensed as a
mail-order drug company
Incumbents vertically integrate New entrants attempt to gain foothold
1) Advisory Board is a subsidiary of UnitedHealth Group the parent company of UnitedHealthCare All Advisory Board research expert perspectives and recommendations remain independent
2) Intermediaries include wholesaler PBM pharmacy
Likely strategy Seek cost and revenue wins
bull Cut out middle men in the pharmaceutical supply chain to lower price reduce own
benefit spend
bull Offer an integrated transparent employer health solution and self-pay consumer platform offer as B2B service to others
bull Capture pharmacy revenue through PillPack
Insurer PBM Pharmacy
Aetna CVS Caremark CVS Pharmacy
Cigna Express Scripts Accredo
UnitedHealth Care1 CatamaranRx BriovaRx
BlueCrossPrime Therapeutics
Walgreens
Integrate medical and pharmacy in attempts to better use advanced analytics steer patients to affiliated specialty pharmacy
Prevent competitors from gaining a leg up through greater vertical integration
Fend off disruption secure pharmaceutical revenue streams
approximate fraction of total drug spending attributable to intermediaries in the pharmaceutical supply chain2
13
Goals of integration Gain competitive edge
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP2
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
3
A sign of the times
Utah health plan for state employees starts pharmacy tourism to Tijuana
Source Alberty E ldquoTo fight high drug prices Utah will pay for public employees to go fill prescriptions in Mexicordquo The Salt Lake Tribune October 29 2018 httpswwwsltribcomnews20181028fight-high-drug-prices Oncology Roundtable interviews and analysis
To fight high drug
prices Utah will pay for public employees to go fill prescriptions
in Mexico
The Salt Lake Tribune
October 28 2018
PEHP pharmacy tourism option
bull Covers 160000 public employees
and their families
bull Offering plane tickets to San
Diego transportation to Tijuana
and $500 cash for patients who
need specific drugs
bull Drugs include those for MS
autoimmune disorders and
prostate cancer (Zytiga)
ldquoWhy wouldnrsquot we pay $300 [in transportation
costs] to go to San Diego drive across to Mexico
and save the system tens of thousands of
dollars If it can be done safely we should be all
over thatrdquo
Rep Norman Thurston R-Provo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
4
A poster child for high costs
National focus on drugs puts cancermdashfairly or unfairlymdashin the spotlight
Source Milliman ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially InsurerdPopulation Claim Data 2004-2014rdquo April 2016 httpwwwmillimancomuploadedFilesinsight2016trends -in-cancer-carepdf IQVIA ldquoGlobal Oncology Trends 2018 Innovation Expansion and Disruptionrdquo May 24 2018 httpswwwiqviacominstitutereportsglobal-oncology-trends-2018 Oncology Roundtable interviews and analysis
35
63
36
62
Medicare Commercial
Cancer Non-cancer
Growth in costs per patient
2004-2014
n=41098 Medicare cancer patients
n=129507 commercial cancer patients
ldquoThe Punishing Cost
of Cancer Carerdquo
ldquoCost of Cancer Is
Becoming Unaffordablerdquo
The New York
Times
TIME
ldquoInsurers Push to Rein in
Spending on Cancer Carerdquo
The Wall
Street Journal
Drug costs on everyonersquos radar
increase in average
cost of new cancer
drugs from 2007-2017100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
5
Exacerbated by rising demand
Utilization will increase with aging population expanding treatment options
Source Colby SL Ortman JM ldquoThe Baby Boom Cohort in the United States 2012 to 2060rdquo US Census Bureau May 2014 httpswwwcensusgovprod2014pubsp25-1141pdf Medicare Chronic Conditions Dashboard httpswwwcmsgovResearch-Statistics-Data-and-SystemsStatistics-Trends-and-ReportsDashboardChronic-Conditions-StateCC_State_Dashboardhtml httpswwwajpmonlineorgarticleS0749-3797(12)00146-8fulltext ldquoGlobal Cancer Immunotherapies Market to 2024 - Increased Uptake of Immune Checkpoint Inhibitors Driving Growth Supported by a Large Robust Pipelinerdquo Research and Markets July 2018 httpswwwresearchandmarketscomresearch9rpwcxglobal_cancerw=4 Oncology Roundtable interviews and analysis
160
178
194
2017 2022 2027
Estimated number of new cancer
cases in the US
55estimated increase in US
population over 65 years of
age from 2010 to 2030
Factors driving increased cancer volumes
33estimated increase in
obesity prevalence in the
US from 2010 to 2030
300estimated increase in
global revenue from cancer
immunotherapy market
from 2018 to 2024
Treatment
options
Lifestyle
factors
Aging
population
In millions
I
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
6
Forcing purchasers to double down on spend
Source Oncology Roundtable interviews and analysis
1 2 3
Drug costs
bull Drug pricing reform
bull 340B
reimbursement
bull Prior authorization
bull Pathways
bull Site neutrality
bull Site-of-care
policies
Site of care Provider choice
bull Network
design
bull Centers of
excellence
Three areas of focus for payers and employers to control costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
7
If you canrsquot beat lsquoemhellip
1 Drug costs
Source Sood N et al ldquoThe Flow of Money Through the Pharmaceutical Distribution Systemrdquo USC Schaeffer Center for Health Policy amp Economics June 2017 Oncology Roundtable interviews and analysis
Amazon-PillPack
Acquisition gives Amazon instant access to all 50 states where PillPack is licensed as a
mail-order drug company
Incumbents vertically integrate New entrants attempt to gain foothold
1) Advisory Board is a subsidiary of UnitedHealth Group the parent company of UnitedHealthCare All Advisory Board research expert perspectives and recommendations remain independent
2) Intermediaries include wholesaler PBM pharmacy
Likely strategy Seek cost and revenue wins
bull Cut out middle men in the pharmaceutical supply chain to lower price reduce own
benefit spend
bull Offer an integrated transparent employer health solution and self-pay consumer platform offer as B2B service to others
bull Capture pharmacy revenue through PillPack
Insurer PBM Pharmacy
Aetna CVS Caremark CVS Pharmacy
Cigna Express Scripts Accredo
UnitedHealth Care1 CatamaranRx BriovaRx
BlueCrossPrime Therapeutics
Walgreens
Integrate medical and pharmacy in attempts to better use advanced analytics steer patients to affiliated specialty pharmacy
Prevent competitors from gaining a leg up through greater vertical integration
Fend off disruption secure pharmaceutical revenue streams
approximate fraction of total drug spending attributable to intermediaries in the pharmaceutical supply chain2
13
Goals of integration Gain competitive edge
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
3
A sign of the times
Utah health plan for state employees starts pharmacy tourism to Tijuana
Source Alberty E ldquoTo fight high drug prices Utah will pay for public employees to go fill prescriptions in Mexicordquo The Salt Lake Tribune October 29 2018 httpswwwsltribcomnews20181028fight-high-drug-prices Oncology Roundtable interviews and analysis
To fight high drug
prices Utah will pay for public employees to go fill prescriptions
in Mexico
The Salt Lake Tribune
October 28 2018
PEHP pharmacy tourism option
bull Covers 160000 public employees
and their families
bull Offering plane tickets to San
Diego transportation to Tijuana
and $500 cash for patients who
need specific drugs
bull Drugs include those for MS
autoimmune disorders and
prostate cancer (Zytiga)
ldquoWhy wouldnrsquot we pay $300 [in transportation
costs] to go to San Diego drive across to Mexico
and save the system tens of thousands of
dollars If it can be done safely we should be all
over thatrdquo
Rep Norman Thurston R-Provo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
4
A poster child for high costs
National focus on drugs puts cancermdashfairly or unfairlymdashin the spotlight
Source Milliman ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially InsurerdPopulation Claim Data 2004-2014rdquo April 2016 httpwwwmillimancomuploadedFilesinsight2016trends -in-cancer-carepdf IQVIA ldquoGlobal Oncology Trends 2018 Innovation Expansion and Disruptionrdquo May 24 2018 httpswwwiqviacominstitutereportsglobal-oncology-trends-2018 Oncology Roundtable interviews and analysis
35
63
36
62
Medicare Commercial
Cancer Non-cancer
Growth in costs per patient
2004-2014
n=41098 Medicare cancer patients
n=129507 commercial cancer patients
ldquoThe Punishing Cost
of Cancer Carerdquo
ldquoCost of Cancer Is
Becoming Unaffordablerdquo
The New York
Times
TIME
ldquoInsurers Push to Rein in
Spending on Cancer Carerdquo
The Wall
Street Journal
Drug costs on everyonersquos radar
increase in average
cost of new cancer
drugs from 2007-2017100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
5
Exacerbated by rising demand
Utilization will increase with aging population expanding treatment options
Source Colby SL Ortman JM ldquoThe Baby Boom Cohort in the United States 2012 to 2060rdquo US Census Bureau May 2014 httpswwwcensusgovprod2014pubsp25-1141pdf Medicare Chronic Conditions Dashboard httpswwwcmsgovResearch-Statistics-Data-and-SystemsStatistics-Trends-and-ReportsDashboardChronic-Conditions-StateCC_State_Dashboardhtml httpswwwajpmonlineorgarticleS0749-3797(12)00146-8fulltext ldquoGlobal Cancer Immunotherapies Market to 2024 - Increased Uptake of Immune Checkpoint Inhibitors Driving Growth Supported by a Large Robust Pipelinerdquo Research and Markets July 2018 httpswwwresearchandmarketscomresearch9rpwcxglobal_cancerw=4 Oncology Roundtable interviews and analysis
160
178
194
2017 2022 2027
Estimated number of new cancer
cases in the US
55estimated increase in US
population over 65 years of
age from 2010 to 2030
Factors driving increased cancer volumes
33estimated increase in
obesity prevalence in the
US from 2010 to 2030
300estimated increase in
global revenue from cancer
immunotherapy market
from 2018 to 2024
Treatment
options
Lifestyle
factors
Aging
population
In millions
I
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
6
Forcing purchasers to double down on spend
Source Oncology Roundtable interviews and analysis
1 2 3
Drug costs
bull Drug pricing reform
bull 340B
reimbursement
bull Prior authorization
bull Pathways
bull Site neutrality
bull Site-of-care
policies
Site of care Provider choice
bull Network
design
bull Centers of
excellence
Three areas of focus for payers and employers to control costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
7
If you canrsquot beat lsquoemhellip
1 Drug costs
Source Sood N et al ldquoThe Flow of Money Through the Pharmaceutical Distribution Systemrdquo USC Schaeffer Center for Health Policy amp Economics June 2017 Oncology Roundtable interviews and analysis
Amazon-PillPack
Acquisition gives Amazon instant access to all 50 states where PillPack is licensed as a
mail-order drug company
Incumbents vertically integrate New entrants attempt to gain foothold
1) Advisory Board is a subsidiary of UnitedHealth Group the parent company of UnitedHealthCare All Advisory Board research expert perspectives and recommendations remain independent
2) Intermediaries include wholesaler PBM pharmacy
Likely strategy Seek cost and revenue wins
bull Cut out middle men in the pharmaceutical supply chain to lower price reduce own
benefit spend
bull Offer an integrated transparent employer health solution and self-pay consumer platform offer as B2B service to others
bull Capture pharmacy revenue through PillPack
Insurer PBM Pharmacy
Aetna CVS Caremark CVS Pharmacy
Cigna Express Scripts Accredo
UnitedHealth Care1 CatamaranRx BriovaRx
BlueCrossPrime Therapeutics
Walgreens
Integrate medical and pharmacy in attempts to better use advanced analytics steer patients to affiliated specialty pharmacy
Prevent competitors from gaining a leg up through greater vertical integration
Fend off disruption secure pharmaceutical revenue streams
approximate fraction of total drug spending attributable to intermediaries in the pharmaceutical supply chain2
13
Goals of integration Gain competitive edge
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
4
A poster child for high costs
National focus on drugs puts cancermdashfairly or unfairlymdashin the spotlight
Source Milliman ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially InsurerdPopulation Claim Data 2004-2014rdquo April 2016 httpwwwmillimancomuploadedFilesinsight2016trends -in-cancer-carepdf IQVIA ldquoGlobal Oncology Trends 2018 Innovation Expansion and Disruptionrdquo May 24 2018 httpswwwiqviacominstitutereportsglobal-oncology-trends-2018 Oncology Roundtable interviews and analysis
35
63
36
62
Medicare Commercial
Cancer Non-cancer
Growth in costs per patient
2004-2014
n=41098 Medicare cancer patients
n=129507 commercial cancer patients
ldquoThe Punishing Cost
of Cancer Carerdquo
ldquoCost of Cancer Is
Becoming Unaffordablerdquo
The New York
Times
TIME
ldquoInsurers Push to Rein in
Spending on Cancer Carerdquo
The Wall
Street Journal
Drug costs on everyonersquos radar
increase in average
cost of new cancer
drugs from 2007-2017100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
5
Exacerbated by rising demand
Utilization will increase with aging population expanding treatment options
Source Colby SL Ortman JM ldquoThe Baby Boom Cohort in the United States 2012 to 2060rdquo US Census Bureau May 2014 httpswwwcensusgovprod2014pubsp25-1141pdf Medicare Chronic Conditions Dashboard httpswwwcmsgovResearch-Statistics-Data-and-SystemsStatistics-Trends-and-ReportsDashboardChronic-Conditions-StateCC_State_Dashboardhtml httpswwwajpmonlineorgarticleS0749-3797(12)00146-8fulltext ldquoGlobal Cancer Immunotherapies Market to 2024 - Increased Uptake of Immune Checkpoint Inhibitors Driving Growth Supported by a Large Robust Pipelinerdquo Research and Markets July 2018 httpswwwresearchandmarketscomresearch9rpwcxglobal_cancerw=4 Oncology Roundtable interviews and analysis
160
178
194
2017 2022 2027
Estimated number of new cancer
cases in the US
55estimated increase in US
population over 65 years of
age from 2010 to 2030
Factors driving increased cancer volumes
33estimated increase in
obesity prevalence in the
US from 2010 to 2030
300estimated increase in
global revenue from cancer
immunotherapy market
from 2018 to 2024
Treatment
options
Lifestyle
factors
Aging
population
In millions
I
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
6
Forcing purchasers to double down on spend
Source Oncology Roundtable interviews and analysis
1 2 3
Drug costs
bull Drug pricing reform
bull 340B
reimbursement
bull Prior authorization
bull Pathways
bull Site neutrality
bull Site-of-care
policies
Site of care Provider choice
bull Network
design
bull Centers of
excellence
Three areas of focus for payers and employers to control costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
7
If you canrsquot beat lsquoemhellip
1 Drug costs
Source Sood N et al ldquoThe Flow of Money Through the Pharmaceutical Distribution Systemrdquo USC Schaeffer Center for Health Policy amp Economics June 2017 Oncology Roundtable interviews and analysis
Amazon-PillPack
Acquisition gives Amazon instant access to all 50 states where PillPack is licensed as a
mail-order drug company
Incumbents vertically integrate New entrants attempt to gain foothold
1) Advisory Board is a subsidiary of UnitedHealth Group the parent company of UnitedHealthCare All Advisory Board research expert perspectives and recommendations remain independent
2) Intermediaries include wholesaler PBM pharmacy
Likely strategy Seek cost and revenue wins
bull Cut out middle men in the pharmaceutical supply chain to lower price reduce own
benefit spend
bull Offer an integrated transparent employer health solution and self-pay consumer platform offer as B2B service to others
bull Capture pharmacy revenue through PillPack
Insurer PBM Pharmacy
Aetna CVS Caremark CVS Pharmacy
Cigna Express Scripts Accredo
UnitedHealth Care1 CatamaranRx BriovaRx
BlueCrossPrime Therapeutics
Walgreens
Integrate medical and pharmacy in attempts to better use advanced analytics steer patients to affiliated specialty pharmacy
Prevent competitors from gaining a leg up through greater vertical integration
Fend off disruption secure pharmaceutical revenue streams
approximate fraction of total drug spending attributable to intermediaries in the pharmaceutical supply chain2
13
Goals of integration Gain competitive edge
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
5
Exacerbated by rising demand
Utilization will increase with aging population expanding treatment options
Source Colby SL Ortman JM ldquoThe Baby Boom Cohort in the United States 2012 to 2060rdquo US Census Bureau May 2014 httpswwwcensusgovprod2014pubsp25-1141pdf Medicare Chronic Conditions Dashboard httpswwwcmsgovResearch-Statistics-Data-and-SystemsStatistics-Trends-and-ReportsDashboardChronic-Conditions-StateCC_State_Dashboardhtml httpswwwajpmonlineorgarticleS0749-3797(12)00146-8fulltext ldquoGlobal Cancer Immunotherapies Market to 2024 - Increased Uptake of Immune Checkpoint Inhibitors Driving Growth Supported by a Large Robust Pipelinerdquo Research and Markets July 2018 httpswwwresearchandmarketscomresearch9rpwcxglobal_cancerw=4 Oncology Roundtable interviews and analysis
160
178
194
2017 2022 2027
Estimated number of new cancer
cases in the US
55estimated increase in US
population over 65 years of
age from 2010 to 2030
Factors driving increased cancer volumes
33estimated increase in
obesity prevalence in the
US from 2010 to 2030
300estimated increase in
global revenue from cancer
immunotherapy market
from 2018 to 2024
Treatment
options
Lifestyle
factors
Aging
population
In millions
I
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
6
Forcing purchasers to double down on spend
Source Oncology Roundtable interviews and analysis
1 2 3
Drug costs
bull Drug pricing reform
bull 340B
reimbursement
bull Prior authorization
bull Pathways
bull Site neutrality
bull Site-of-care
policies
Site of care Provider choice
bull Network
design
bull Centers of
excellence
Three areas of focus for payers and employers to control costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
7
If you canrsquot beat lsquoemhellip
1 Drug costs
Source Sood N et al ldquoThe Flow of Money Through the Pharmaceutical Distribution Systemrdquo USC Schaeffer Center for Health Policy amp Economics June 2017 Oncology Roundtable interviews and analysis
Amazon-PillPack
Acquisition gives Amazon instant access to all 50 states where PillPack is licensed as a
mail-order drug company
Incumbents vertically integrate New entrants attempt to gain foothold
1) Advisory Board is a subsidiary of UnitedHealth Group the parent company of UnitedHealthCare All Advisory Board research expert perspectives and recommendations remain independent
2) Intermediaries include wholesaler PBM pharmacy
Likely strategy Seek cost and revenue wins
bull Cut out middle men in the pharmaceutical supply chain to lower price reduce own
benefit spend
bull Offer an integrated transparent employer health solution and self-pay consumer platform offer as B2B service to others
bull Capture pharmacy revenue through PillPack
Insurer PBM Pharmacy
Aetna CVS Caremark CVS Pharmacy
Cigna Express Scripts Accredo
UnitedHealth Care1 CatamaranRx BriovaRx
BlueCrossPrime Therapeutics
Walgreens
Integrate medical and pharmacy in attempts to better use advanced analytics steer patients to affiliated specialty pharmacy
Prevent competitors from gaining a leg up through greater vertical integration
Fend off disruption secure pharmaceutical revenue streams
approximate fraction of total drug spending attributable to intermediaries in the pharmaceutical supply chain2
13
Goals of integration Gain competitive edge
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
6
Forcing purchasers to double down on spend
Source Oncology Roundtable interviews and analysis
1 2 3
Drug costs
bull Drug pricing reform
bull 340B
reimbursement
bull Prior authorization
bull Pathways
bull Site neutrality
bull Site-of-care
policies
Site of care Provider choice
bull Network
design
bull Centers of
excellence
Three areas of focus for payers and employers to control costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
7
If you canrsquot beat lsquoemhellip
1 Drug costs
Source Sood N et al ldquoThe Flow of Money Through the Pharmaceutical Distribution Systemrdquo USC Schaeffer Center for Health Policy amp Economics June 2017 Oncology Roundtable interviews and analysis
Amazon-PillPack
Acquisition gives Amazon instant access to all 50 states where PillPack is licensed as a
mail-order drug company
Incumbents vertically integrate New entrants attempt to gain foothold
1) Advisory Board is a subsidiary of UnitedHealth Group the parent company of UnitedHealthCare All Advisory Board research expert perspectives and recommendations remain independent
2) Intermediaries include wholesaler PBM pharmacy
Likely strategy Seek cost and revenue wins
bull Cut out middle men in the pharmaceutical supply chain to lower price reduce own
benefit spend
bull Offer an integrated transparent employer health solution and self-pay consumer platform offer as B2B service to others
bull Capture pharmacy revenue through PillPack
Insurer PBM Pharmacy
Aetna CVS Caremark CVS Pharmacy
Cigna Express Scripts Accredo
UnitedHealth Care1 CatamaranRx BriovaRx
BlueCrossPrime Therapeutics
Walgreens
Integrate medical and pharmacy in attempts to better use advanced analytics steer patients to affiliated specialty pharmacy
Prevent competitors from gaining a leg up through greater vertical integration
Fend off disruption secure pharmaceutical revenue streams
approximate fraction of total drug spending attributable to intermediaries in the pharmaceutical supply chain2
13
Goals of integration Gain competitive edge
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
7
If you canrsquot beat lsquoemhellip
1 Drug costs
Source Sood N et al ldquoThe Flow of Money Through the Pharmaceutical Distribution Systemrdquo USC Schaeffer Center for Health Policy amp Economics June 2017 Oncology Roundtable interviews and analysis
Amazon-PillPack
Acquisition gives Amazon instant access to all 50 states where PillPack is licensed as a
mail-order drug company
Incumbents vertically integrate New entrants attempt to gain foothold
1) Advisory Board is a subsidiary of UnitedHealth Group the parent company of UnitedHealthCare All Advisory Board research expert perspectives and recommendations remain independent
2) Intermediaries include wholesaler PBM pharmacy
Likely strategy Seek cost and revenue wins
bull Cut out middle men in the pharmaceutical supply chain to lower price reduce own
benefit spend
bull Offer an integrated transparent employer health solution and self-pay consumer platform offer as B2B service to others
bull Capture pharmacy revenue through PillPack
Insurer PBM Pharmacy
Aetna CVS Caremark CVS Pharmacy
Cigna Express Scripts Accredo
UnitedHealth Care1 CatamaranRx BriovaRx
BlueCrossPrime Therapeutics
Walgreens
Integrate medical and pharmacy in attempts to better use advanced analytics steer patients to affiliated specialty pharmacy
Prevent competitors from gaining a leg up through greater vertical integration
Fend off disruption secure pharmaceutical revenue streams
approximate fraction of total drug spending attributable to intermediaries in the pharmaceutical supply chain2
13
Goals of integration Gain competitive edge
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
8
Public payers extremely concerned
Trying to control drug costs through transparency and competition
Source Federal Register ldquoMedicare and Medicaid Programs Regulation To Require Drug Pricing Transparencyrdquo Centers for Medicare amp Medicaid Services October 2018 Increases in Reimbursement for Brand-Name Drugs in Part D US Department of Health amp Human Services Office of Inspector General June 2018 ldquoOffice of Generic Drugs Annual Report for 2017rdquo US Food amp Drug Administration July 2018 Commins J ldquoMedicare Advantage Plans Given Negotiating Power on Part B Drug Pricesrdquo HealthLeaders August 2018 Leonard K ldquoSenate unanimously passes bill banning pharmacy gag clauses in Medicarerdquo Washington Examiner September 2018 Oncology Roundtable interviews and analysis
generic drugs approved in 20171027
FDA expedites drug approval processWe are not counting on
voluntary reductions in pricerdquo
Alex Azar Secretary of HHS
US Senate Hearing June 26 2018
Medicare advantage
utilization constraints
MA plans now have the
option to impose prior
authorization and step
therapy requirements on drug
formularies for Part B drugs
estimates $24B in savings
Notable federal actions to address rising drug costs in 2018
Patients Right to Know
Drug Prices Act
Blocks insurers and pharmacy
benefit managers (PBMs)
from prohibiting pharmacies of
informing customers of lower
priced drug options outside of
their insurance
Drug pricing
transparency
Proposed CMS rule
would require drug
manufacturers to post list
prices of drugs in direct-
to-consumer
advertisements
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
9
Seeking parity with international drug prices
Innovation Center to test new payment model for Medicare Part B drugs
Source Federal Register ldquoMedicare Program International Pricing Index Model for Medicare Part B Drugsrdquo Centers for Medicare amp Medicaid Services October 2018 Oncology Roundtable interviews and analysis
New ldquomodel vendorsrdquo responsible for
negotiating drug prices competing for
provider business and billing Medicare1
Provisions of proposed International Pricing
Index Model for Medicare Part B drugs
CMS reimbursement indexed to prices
paid by international countries phased in
over five year period
Providers reimbursed a set add-on
payment amount instead of average sales
price plus 623
Subset of Part B
single-source drugs
and biologicals in
select geographic
regions1) Model vendors can be wholesalers specialty pharmacies group purchasing organizations manufacturers individual or groups of
physicians and hospitals manufacturers Part D sponsors andor other entities that satisfy vendor qualification requirement s
2) Physician and hospital add-on payment is a set amount calculated based on what CMS would have paid in the absence of the model reflecting 6 percent of historical drug costs (before sequestration) redistributed as a set payment
3) Medicare pays ASP plus 43 post-sequestration
Physician-
administered
drugs
All prescription drugs
higher acquisition cost in the US
compared to 16 other developed
economies for 27 Part B drugs
included in CMS analysis
80
Subset of drugs currently included
Drugs in
model
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
10
Targeting pharmacy benefit managers
Unclear implications of Part D rebate proposal on federal spending
Source Sachs R ldquoTrump Administration Releases Long-Awaited Drug Rebate Proposalrdquo HealthAffairs February 1 2019 httpswwwhealthaffairsorgdo101377hblog20190201545950full Oncology Roundtable interviews and analysis
Current regulatory safe harbor
bull Pharmaceutical companies encouraged to
set high list price for drug
bull Negotiate with PBMs for rebate off the
list price
bull Rebates paid to PBM after sale to patient
savings usually not passed on to patient
bull Patients often responsible for list price
rather than lower negotiated price
New safe harbor regulations
bull Two new safe harbors could include
ndash Rebates passed onto patient at point
of sale
ndash Flat service fee payment made to PBMs
not tied to list price of drug
bull Goal is to lower out-of-pocket payments for
beneficiaries and list prices
bull Biggest impact on competitive drug markets
Potential implications
Patient spend would likely decrease Federal spend depends on stakeholder response
Monthly premiums
Out-of-pocket costs
$1399B increase from 2020-2029 according to
one analysis
$996B decrease from 2020-2029 according to
another analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
11
Trying to de-mystify the drug value equation
Source McGinley L ldquoCancer drug prices are so high that doctors will test cutting dosesrdquo The Washington Post June 8 2017 httpswwwwashingtonpostcomnewsto-your-healthwp20170608how-these-cancer-doctors-plan-to-reduce-patients-drug-costs-without-touching-pricesutm_term=603e11ac7682 Oncology Roundtable interviews and analysis
Value in Cancer Care
Consortium (vi3c)
bull Nonprofit started by
oncologists with goal of
improving access
affordability sustainability
bull Trials focus on optimizing
delivery of drugs and
comparing regimens
bull Early trial showing equal
outcomes with reduced
dosage of abiraterone
with food leads NCCN to
update prostate cancer
guidelines in March 2019
1 2 3
Innovation and Value
Initiative (IVI)
bull Non-profit with the goal of
building a platform to
assess value of treatments
tailored to individual needs
and interests
bull Current open-source value
models include RA and
EGFR+ NSCLC
bull Allows users to compare
treatment options and
sequencing based on
preferences and desired
outcomes
Three organizations focusing on drug ldquovaluerdquo
Institute for Clinical and
Economic Review (ICER)
bull Independent research
organization that provides
ldquovalue-based price
benchmarkrdquo reflecting
appropriate pricing
relative to impact on
outcomes
bull Framework consists of
care value (comparison of
clinical and cost
effectiveness) and health
system value (measure of
five-year budget impact on
health systems)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
12
Private payers seek to inflect treatment decisions
Turn to prior authorizations and clinical pathways
Source ASCO Daily News ldquoASCO Ensures Clinical Pathways in Oncology Promote Patient Carerdquo ASCO Daily News May 26 2016 httpsamascoorgdaily-newsasco-ensures-clinical-pathways-oncology-promote-patient-care ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Edittionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf ldquoGenentech Oncology Trend Report Ninth Editionrdquo Genentech httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2017_Genentech_Oncology_Trend_Reportpdf 2017 Trending Now in Cancer Care Survey Oncology Roundtable interviews and analysis
1) 48 of payers following cancer treatment pathways indicate that they provide incentives to physicians to treat on pathway
The burden of prior
authorization increasing
89of cancer programs indicate that the
percentage of services requiring prior
authorization has increased over the
past 12 months
91 of payers use prior
authorizations to control
oncology costs
50 of payers have increased
prior authorization under the
medical benefit since 2015
$350 paid by Anthem to
oncologists each month per
patient treated on pathway
34 of payers follow cancer
treatment pathways1
Exploring clinical
pathways programs
Cancer Care Quality
Program
BlueCross BlueShield of
North Carolinarsquos Medical
Oncology Program
Sample payer programs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
13
Ongoing controversy around 340B rate cuts
Ruling jeopardizes 2018 cuts impact unclear while awaiting further activity
Source ldquoReport to the Congress Overview of the 340B Drug Pricing Programrdquo Medicare Payment Advisory Commission May 2015 ldquoCY 2018 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquoCY 2019 Hospital Outpatient Prospective Payment System Final Rulerdquo CMS ldquo340B cuts are illegal judge rules Is lsquohavocrsquo coming for hospitalsrsquo The Daily Briefing Advisory Board Jan 2 2019 Gaty B lsquoCourt reverses 340B reimbursement cutrsquo Urology Times Jan 30 2019 Oncology Roundtable interviews and analysis
1) MEDPAC using language from HRSA in May 2015 report
2) MEDPAC estimate from May 2015 report
3) Rate cut excludes vaccines and pass-through drugs
4) Average Sales Price
5) Childrenrsquos hospitals PPS-exempt cancer hospitals and rural sole community hospitals exempted from the payment rate cut Critical access hospitals and Maryland waiver hospitals are not affected
6) Hospital Outpatient Prospective Payment System
7) American Hospital Association Association of American Medical Colleges Americas Essential Hospitals Eastern Maine Healthcare Systems Henry Ford Health System in Detroit and Park Ridge Health Hendersonville North Carolina sued CMS over the cuts in September 2018
340B program overview
bull Created in 1992 the 340B Drug Pricing Program requires drug manufacturers to provide separately
payable Part B drugs to eligible health care organizations at reduced prices
bull The programrsquos intent is to ldquostretch
scarce federal resources as far as possible to provide more care to
more patientsrdquo1
bull An estimated 45 of hospitals participate in 340B2
340B cuts in the 2018 2019 final Medicare rules
bull Reimbursement for separately payable Part B drugs 3 cut from ASP4+6 to ASP-225 in 2018 for most hospitals5 resulting in $16B estimated savings in 2018
bull Savings redistributed to non-drug HOPPS6 services across all hospitals
bull Rate cuts extended to 115 non-excepted HOPDs in 2019
Legal update
bull In December 2018 a federal judge issued a permanent injunction on the 340B rate cuts on the grounds that CMS overstepped its authority
bull The judge did not vacate the 2018 final rule but requested further briefing from HHS and the lawsuit plaintiffs7 to determine remedy
bull Imminent impact unlikely given likely appeal from CMS
and uncertainty surrounding current state
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
14
Private payers home in on cost differential
Source ldquoCost Drivers of Cancer Care A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 200 4-2014rdquo Milliman httpwwwmillimancomuploadedFilesinsight2016trends-in-cancer-carepdf ldquoThe Value of Community Oncology Site of Care Cost Analysisrdquo Community Oncology httpswwwcommunityoncologyorgwp-contentuploads201709Site-of-Care-Cost-Analysis-White-Paper_92517pdf ldquoMagellan Rx Management Medical Pharmacy Trend Report Eighth Editionrdquo Magellan Rx Management httpswww1magellanrxcommedia722153tr2017_final_for-website-usepdf Oncology Roundtable interviews and analysis
6
46
2004 2014
Percentage of chemotherapy infusions
delivered in hospital-based setting
For private payers
increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
private payers compared to physician office
42
Brand namePhysician
officeHospital
outpatient
Herceptin $4131 $7737
Rituxan $7328 $11451
Avastin $2415 $9471
Remicade $4691 $10995
2 Site of care
Increase in hospital-based infusions contributing to higher costs
Cost of select infused drugs to
private payers by site of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
15
Moving to manage site of care
Private payers looking to shift infusions to lowest-cost setting
Source ldquoEMD Serono Specialty Digest 12th edition Managed Care Strategies for Specialty Pharmaciesrdquo EMD Serono httpspecialtydigestemdseronocomDefaultaspx Oncology Roundtable interviews and analysis
Commercial health
plan goals
Cost-containment
programs
Require preferred site
use with limited medical
exception
Contact patients to
recommend lower-cost
site of care
Encourage patients to
select lower-cost sites
with reduced cost sharing
12
64
report ldquomoving infusions to
the lowest-cost site of carerdquo
as the top priority for the
next 12-24 months
report ldquomoving infusions to
the lowest-cost site of carerdquo
as a top five priority for the
next 12-24 months
report that site-of-care
initiatives are the most
important strategy to
manage specialty drug costs
19
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
16
CMS taking significant steps towards site neutrality
Source ldquoCY 2019 HOPPS Final Rulerdquo CMS httpswwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHospitalOutpatientPPSindexhtml Oncology Roundtable interviews and analysis
Overview of CMSrsquo activity towards
establishing site neutrality
2016
Creates modifier to track off-
campus HOPD services
2017
Sets payment for non-excepted
HOPDs are 50 of HOPPS rate
2018
Reduces payment for non-excepted
HOPDs to 40 of HOPPS rate
2019
Sets two-part clinic visit payment rate
cut at all off-campus HOPDs
$110
$192
$159
$124
Physicianoffice
2018 2019 2020
Clinic visit G0463 payment rates
Off-campus HOPDs
13 difference in
reimbursement rate
by 2020
Reducing clinic visit payment for all off-campus HOPDs this year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
17
Refresher Excepted vs non-excepted sites
Some off-campus HOPDs receive site-neutral rates for all services
Source CMS CY 2019 HOPPS Final Rule Advisory Board research and analysis
1) Except for routine clinic visit code G0463 for which excepted off-campus providers will be paid only 70 of the HOPPS rate in 2019
2) Facilities that are forced to move as a result of extraordinary circumstances (eg natural disaster) will not lose their excepted status Extraordinary circumstance determination made at discretion of CMS Regional Office
Defining an Off-Campus HOPD
Non-excepted providersExcepted off-campus providers
bull Off-campus hospital outpatient departments
that did not furnish services payable under
HOPPS prior to November 2 2015
bull Previously excepted providers that have lost
excepted status since January 1 2017
bull Off-campus hospital outpatient departments
that furnished services payable under
HOPPS prior to November 2 2015 or that
were mid-build at that time
Receive full HOPPS rate1 Receive 40 of HOPPS rate
bull Any point of the HOPD is located at
least 250 yards from any point of the
hospital facility
bull Financial operations and clinical
services fully integrated with those
of the main hospital
bull Held out to public as part of the
main hospital
Facility Relocation2
Change in HOPD and
Hospital Relationship
Excepted Status Can Be Lost in
Two Ways
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
18
Employer health spending continues to grow
Oncology costs rising to the top of their priority list
3 Provider choice
Source HCCI ldquo2016 Health Care Cost and Utilization Reportrdquo January 2018 Willis Towers Watson ldquoBest Practices in Health Care Empl oyer Survey Reportrdquo January 31 2018 PwC ldquoMedical cost trend Behind the numbers 2018rdquo June 2017 Mercer ldquoMercer Survey Shows Employers Face a 43 Increase in 2018 US Health Benefit Cost Highest Since 2011 But Trend Stablerdquo September 18 2017 Nobel J et al ldquoCancer and the Workplace The Employer Perspectiverdquo Northeast Business Group on Health httpnebghorgwp-contentuploads201510CancerWorkplace_FINALpdf Henry J Kaiser Family Foundation Oncology Roundtable interviews and analysis
28 27
4146
2013 2014 2015 2016
Employer health care spending continues to rise
Oncology a major financial burden
of employersrsquo claims are
cancer-related
1of employersrsquo medical
costs are cancer-related
12estimated employer spend on direct
and indirect costs of cancer in 2015
$264B
Percent change in annual spending per person relative to previous year
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
19
Adding new layers of control
Embracing activation in addition to delegation
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Spectrum of options for controlling health benefits expense
Activation
bull Shift employees to public exchange
bull Trade Cadillac tax
for employer mandate penalty
Drop coverage
bull Encourage employee uptake of HDHPs
bull Outsource administrative
burden to third party such as a private exchange
Shift risk
Delegation Abdication
bull Curate network design to influence employee choice
bull Active episodic-specific steerage
Manage proactively
Recent era of employer strategy
Emerging era of employer strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
20
Centers of excellence regain momentum
Source ldquoNext Generation Health Carerdquo Healthcare Financial Managementrdquo httpwwwbdcadvisorscomwp-contentuploads2016030316_hfm_Next_Gen_Healthcarepdf Mayo Clinic Rochester MN Walmart Bentonville AR Oncology Roundtable interviews and analysis
Looking for partners to drive quality reduce costs
3
9
18
12
16
26
22
19
39
50
31
30
31
19
15
Cancer
Cardiovascular
Knees hips or
spine
Bariatric surgery
Transplants
Yes with incentives Yes but no incentives
Status of large employersrsquo contracts with
centers of excellenceWalmart and Mayo Clinic
bull Expanded center of excellence
partnership in 2015 to include breast lung
colon and rectal cancers
bull Employees diagnosed with cancer
encouraged to have case reviewed to
determine if they would benefit from
traveling to Mayo
bull If travel is recommended Walmart covers
cost for employee and family member
CASE EXAMPLE
30of eligible
employees travel
to Mayo for care
55of patients who travel
have treatment plans
changed
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
21
Oncology Roundtable insight
Cancer programsrsquo price is purchasersrsquo
top cost priority
The private and public sectors are using the mechanisms
most within their control to rein in oncology spendmdash
namely cutting reimbursement to providers and steering
patients to lower-cost sites of care Cancer programs
need to monitor local market activity react swiftly to
changing regulations and optimize their cost structure to
protect volumes and revenue
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
22
The margin problem
Expense growth already outpacing revenue growth for most hospitals
Source Moodyrsquos Investors Service ldquoUS NFP amp Public Hospitalsrsquo Annual Medians Show Expense Growth Topping Revenues for Second Yearrdquo August 28 2018 Moodyrsquos Investors Service ldquoRevenue Growth and Cash Flow Margins Hit All -Time Lows in 2013 US Not-for-Profit Hospital Mediansrdquo August 2014 Health Care Advisory Board Toward True Sustainability Washington DC Advisory Board 2018 Rege A ldquoThe No 1 priority for hospital CEOs Cost controlrdquo Beckerrsquos Hospital Review July 11 2018 httpswwwbeckershospitalreviewcomhospital -management-administrationthe-no-1-priority-for-hospital-ceos-cost-controlhtml Oncology Roundtable interviews and analysis
Revenue and expense growth rates
for non-profit hospitals
2009-2017 medians
2
4
6
8
2010 2012 2014 2016 2018
Revenue growth Expense growth
Staffing
Traditional financial
pressures
Drugs and supplies
Capital investments
Service utilization
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
23
Resources to maximize oncology margins
Source Oncology Roundtable interviews and analysis
bull Reduce Unwarranted Care Variation in Oncology
bull Redesigning Cancer Care Delivery
for the Era of Accountability
bull The Three-Step Cancer Staffing Makeover
bull Oncology Volumes Staffing and Operations Benchmark Generators
bull Improving End-of-Life Care for Cancer Patients
bull The Infusion Center Billing Strategy Playbook
bull Infusion Center Pro Forma
bull Prior Authorization for Physician-Administered Drugs
bull Use Financial Data to Diagnose
Gaps in Performance
bull 5 Things You Need to Know About Specialty Pharmacy Strategy
bull Cancer Patient Financial
Navigation
bull Help Patients Understand Their Financial Responsibility
bull Tap into All Available
Assistance
bull Oncology Growth Strategy
bull The Tumor Site Strategy Toolkit
bull Online Cancer Program
Marketing
bull Cancer Patient Experience Survey Resources
bull Elevating Oncology Referral
Strategy
bull Strategic Employer Partnerships for Cancer Care
bull Clinical Innovations in Oncology
Register now for Managing Oncology Drug Costs on June 13 by visiting advisorycom
Contain cost
growth
Maximize revenue
capture
Capture new
growth
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
24
Meeting the demands of the future will prove costly
Three trends impacting future cancer program investments
Source Oncology Roundtable interviews and analysis
1) Includes 247 patient access one navigator one data analyst and upfront cost of care planning software
Annual cost of meeting initial requirements for Oncology Care Model participation1
Start-up cost including lab equipment data management and annual salaries for
precision medicine capabilities
Annual salary cost for dietitian palliative care and behavioral health specialists
~$400Kgt$1M$500K-$1M
Evolving diagnostic and
treatment options
Increasing consumer
demands
bull Purchasers increasingly
deploy reimbursement
models that reward value
over volume
bull Changing payment models
force providers to live in
prolonged period of
investment experimentation
bull Rapid increase in
knowledge of how to detect
diagnose and treat cancer
bull New costly innovations
spur investment in
expertise and infrastructure
despite unclear
reimbursement
bull Patients become more
involved in decisions about
where they go and stay
for care
bull Focus on best-in-class
experience creates urgency
to invest in expensive
service enhancements
Shifting payment
models
Sample costs
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
25
Confronting new financial pressures
Source Oncology Roundtable interviews and analysis
Ma
rgin
s
Value-based care
Clinical innovations
Patient experience
Immediate cost pressures Emerging cost pressures
Staffing
Drugs and supplies
Capital investments
Service utilization
1
2
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP26
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
27
What have we learned so far
Years of payment reform experiments raise more questions than answers
Pressure 1 Value-based care
Source Oncology Roundtable interviews and analysis
1) Regional Cancer Care Associates
Both parties need to weigh the administrative
burden of payment reform against the number
of patients it will cover and benefit
Bundled payments
Shared savings and ACOs
Oncology medical homes
bull MD Anderson and UHC
bull Moffitt and UHC
bull 21st Century Oncology and Humana
bull RCCA1 and Horizon BCBS
bull Miami Cancer Institute and Florida Blue
bull Moffitt and Florida Blue
bull Aetna Oncology Medical Home
Collaborative
bull Priority Healthrsquos Michigan Oncology
Medical Home Demonstration Project
Key takeawaysSample private payer-led
value-based oncology models
It is often difficult to pinpoint the reasons for
success or failure but top opportunities to reduce
costs are standardizing care reducing ED and
hospital use and improving end-of-life care
The biggest benefit to payers and providers is
developing relationships and sharing data to
better understand the cost and quality of care
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
28
The 800-pound gorilla takes on oncology
Oncology Care Model entering its fourth year
Source CMS Oncology Care Model httpsinnovationcmsgovinitiativesoncology-care Oncology Roundtable interviews and analysis
bull 176 medical oncology practices
bull 10 payers
bull CMS
Who is
participating
bull Fee-for-service payments for all services to enrolled beneficiaries
bull Monthly enhanced oncology services
(MEOS) payment of $160 for six months upon initiation of chemo
ndash If the patient continues or resumes chemo practice can trigger subsequent episodes
How are
practices paid
bull Performance-based payment provided if practice reduces beneficiariesrsquo total Medicare billings and meets threshold for
quality performance
ndash Quality measured relative to other practices
ndash Cost performance is evaluated against
historic performance
bull Provide 247 access to appropriate clinician with real-time access to medical records
bull Provide the core functions of patient navigation
bull Document a care plan with the 13 components recommended by
the IOM
bull Treat patients on nationally recognized clinical guidelines
bull Use certified electronic health
record technology (CEHRT)
bull Utilize data for continuous quality improvement
What are the requirements
for participating providers
Overview of the Oncology Care Model (OCM)
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
29
Not the results we were hoping for
Too early to draw conclusions but participants split on value
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
=
Performance Period (PP) 1 results
Quality
Against the comparator group
the OCM cohort hadhellip
Small reductions in admissions
and ICU stays at end of life
= Costs
Slightly declined total costs of care
not including MEOS payments
Key caveats
bull Delayed roll out of data
bull Many practices just starting to implement cost-savings initiatives
bull Methodology concerns eg attribution
tumor-specific risk adjustment novel therapy adjustment
37
33
27
27
24
31
12
8
Loweredcost ofcare
Increasedquality of
care
No not at all Too early to tell
Yes somewhat Yes significantly
OCM participantsrsquo perception of value
n=51 oncologists participating in OCM
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
30
Dec
PP1 external
evaluation
published
Only two more years till planned end point
Participants reach critical decision point in 2019
1) After initial reconciliation but before true up Percentage will likely decrease slightly
Source ldquoCMS announces additional opportunities for clinicians to join innovative care approaches under the Quality Payment Programrdquo Centers for Medicare amp Medicaid Services httpswwwcmsgovNewsroomMediaReleaseDatabasePress-releases2016-Press-releases-items2016-10-25html ldquoOncology Care Model Overviewrdquo Association of Community Cancer Centers httpoiaccc-cancerorgadvocacyOCM-Overviewasp Strawbridge L ACCC Oncology Care Model Collaborative Workshop at the ACCC 44th Annual Meeting and Cancer Business Summit Washington DC March 16 2018 Oncology Roundtable interviews and analysis
Timeline of key OCM events
July-Sept
Measurement
Period 1
July 1
OCM begins
w ith 190
participating
practices
June 30
End of
Performance
Period 1
Nov-Dec
OCM registry
available to
report clinical
and quality data
June 30
Anticipated
performance
period end date
201820172016 2019 2020 2021
Summer-Fall
Practices that have not earned a
bonus in any of f irst four
performance periods decide to
enter two-sided risk or drop out
Jan 1
Practices can
enter into either
tw o-sided risk
option
PP1 PP2
25 30
Percent of participants earning
a bonus
PP31
33
bull Reduced discount (25)
bull Stop-gain and stop-loss amounts based on revenue rather than cost benchmark
bull Minimum loss threshold of 25 before recoupment activated
Highlights of new two-sided risk model
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
31
Comparing the options
Source CMMI OCM Performance Payment Methodology December 17 2018 innovationcmsgovFilesxocm-pp3beyond-pymmethpdf Oncology Roundtable interviews and analysis
Risk Arrangement
One-sided risk Original two-sidedrisk Alternative two-sided risk
OCM discount 4 of benchmark 275 of benchmark 25 of benchmark
Performance-based payment
based onhellip
Actual lt target Actual lt target Actual lt target
Performance-based payment
calculated onhellip
Target ndash actual Target ndash actual Target ndash actual
Stop-gain 20 of benchmark 20 of benchmark 16 of revenue + chemo
Recoupment is the following is
truehellip
NA Actual gt target Actual gt benchmark
Recoupment based on this
differencehellip
NA Actual - target Actual ndash benchmark
Stop-loss NA 20 of benchmark 8 of revenue + chemo
Advanced APM status No Yes Yes
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
32
This isnrsquot new territory for CMS
1) Medicare Shared Savings Program Source Cinque M ldquoThe strategy many ACOs call the secret to MSSP success rdquo Advisory Boardrsquos Daily Briefing November 21 2013 Lazerow R ldquoFour takeaways on the recent ACO results CMS Fact Sheet August 25 2016 Sinclair H ldquoLast yearrsquos MSSP results are out Here are our 5 key takeawaysrdquo Advisory Boardrsquos Daily Briefing October 31 2017 Oncology Roundtable interviews and analysis
MSSP1 Participation and Financial Performance 2012-2017
Program performance
year
Number of
ACOs
Spending below target
savings
Spending below target no savings
Spending above target
Net impact to Medicare
PY1 2012-2013 220 26 27 47 ($78M)
PY 2014 333 28 27 46 ($50M)
PY 2015 392 31 21 48 ($216M)
PY 2016 432 31 25 44 ($39M)
PY 2017 472 34 26 39 $314
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
33
Still evolving the model
ldquoPathways to Successrdquo rule at end of 2018 changes MSSP again
Source Health Care Advisory Board Oncology Roundtable interviews and analysis
Current Structure Change New Structure
Track 1
3-year agreement upside-only
Consolidated and adapted
BASIC Track
5-year agreement
First two years upside-only
Last three years 30 fixed loss rateTrack 1+
3-year agreement 30 fixed loss rate
Track 2
3-year agreement up to 60 loss rateEliminated
No equivalent financial model under proposed structure
Track 3
3-year agreement up to 75 loss rateRebranded
ENHANCED Track
5-year agreement up to 75 loss rate
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
34
No shortage of ideas for OCM 20
Source HHS Physician-Focused Payment Model Technical Advisory Committee httpsaspehhsgovproposal-submissions-physician-focused-payment-model-technical-advisory-committee Oncology Roundtable interviews and analysis
Comprehensive
Cancer Care
Delivery Model
Patient-Centered
Oncology Payment
Model (PCOP)
1 2 3
Recommended for implementation
Recent oncology-related models proposed to physician-focused Payment
Model Technical Advisory Committee (PTAC)
Active proposals letters of intent submitted
bull Submitted by Community Oncology Alliance (COA)
bull Builds on Oncology Care
Model but starts with any treatment and follows patients to survivorship or end of life
bull One- and two-sided risk
options both including risk-adjusted care management
feeds and shared savings based on total costs of care
bull Submitted by ASCO
bull Provides supplemental payment for treatment
planning care management and clinical trial participation
bull Includes a two-sided risk
option based on quality measurement reporting
and treatment pathway compliance
Making Accountable
Sustainable Oncology
Networks (MASON)
bull Based on principles of Community Oncology Medical Home (COME HOME)
bull Participants would be equipped with triage pathways diagnostic and therapeutic pathways
cognitive computing platform and data science processes
bull Cost targets based on Oncology
Payment Categories (OPCs) shared savings based on cost and quality performance
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
35
Radiation therapy bundle in the works
Expecting a proposal in the coming months
Source Hubbard A ldquoRO-APM What we know what we donrsquot and what it all meansrdquo ASTRO Blog February 14 2019 httpswwwastroorgBlogFebruary-2019RO-APM-What-we-know-what-we-donE28099t-and-what-it-all Oncology Roundtable interviews and analysis
What we know Top questions
bull Will the model be mandatory
bull How many practices will be required
to participate
bull Will it meet the criteria to be an
advanced alternative payment model
bull How will payment methodology be
constructed
bull How will payment be made to centers
that bill globally
bull Which 17 cancer types will be included
Mandated by Congress in
2015 Patient Access and
Medicare Protection Act
Will be applicable to
hospital and
freestanding providers
Will include prospective payment
for 90-day episode of care one
payment at beginning of episode
and one at conclusion
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
36
Oncology Roundtable insight
Value-based care model redesign will
result in continuous changes to your
investment roadmap
The lack of clear results from oncology payment reform to
date means that providers and payers will continue to
iterate on existing models and experiment with alternative
models in the coming years This puts cancer programs at
risk of sinking money into ineffective program redesign
initiatives To avoid doing this cancer programs need to
prioritize investments that are win-win in both worlds such
as evidence-based care improved access symptom
management and data infrastructure
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
37
Entering a new age of science
Are you expecting new types of competition
Pressure 2 Clinical innovations
Source Cooke H ldquoFDA approved 23adnMe Inc to distribute direct-to-consumer genetic test for colorectal cancer riskrdquo Prevent Cancer January 2019 httpspreventcancerorg201901fda-approves-23andme-inc-to-distribute-direct-to-consumer-genetic-test-for-colorectal-cancer-risk Sneed A ldquoMail-Order CRISPR Kits Allow Absolutely Anyone to Hack DNArdquo Scientific American November 2 2017ldquohttpswwwscientificamericancomarticlemail -order-crispr-kits-allow-absolutely-anyone-to-hack-dna Oncology Roundtable
interviews and analysis
Direct-to-consumer testing
ldquoPrevent Cancer Foundationreg
warns the test may have unintended consequences for
cancer preventionrdquo
ldquoMail-Order CRISPR Kits
Allow Absolutely Anyone to Hack DNArdquo
ldquoExperts debate what amateur scientists
could accomplish with the powerful DNA editing toolmdashand whether its ready
availability is cause for concernrdquo
At-home DNA repair
ldquoFDA Approves 23andMe to Distribute
Direct-to-Consumer Genetic Test for Colorectal Cancer Riskrdquo
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
38
Wersquove already come a long way
Improvements in cancer detection treatment decreases mortality rates
Source SEER httpseercancergovstatfactshtmlallhtml American Society of Clinical Oncology httpwwwcancernet Hanna N Einhorn LH ldquoTesticular Cancer A Reflection on 50 Years of Discoveryrdquo Journal of Clinical Oncology 32 no 28 (2014) 3085-3092 Oncology Roundtable interviews and analysis
Longstanding focus on
personalizing treatment for outsized gains
increase in five-
year survival for chronic
myeloid leukemia due
to the use of Gleevec
2x
9x increase in five-
year survival for
testicular cancer due to
the use of cisplatin
214
201
187
172
156
1992 1998 2004 2010 2016
Cancer mortality rates in the US
Cancer-related deaths per 100000 population
gt25M deaths avoided since 1992
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
39
Transforming how we detect and treat cancer
Prevalence
Adoptive cell transfer1 Organoids
Tra
nsfo
rma
tive
po
ten
tia
l o
ve
r n
ext 3
-5 y
ea
rs
Widespread In research
Source Oncology Roundtable interviews and analysis
Liquidbiopsies
Breathalyzer
Checkpoint inhibitors
Oncolyticvaccines
Real-time efficacymonitoring
1) Includes CAR T and tumor infiltrating lymphocyte (TIL) therapies
Sample diagnostic and treatment innovations
Hormone therapy
Single target gene testing
Multi-gene panels
Next-generationsequencing
Whole-exome sequencing
Antibody drug conjugates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
40
Aiming for actionable less invasive follow up
More work needed before liquid biopsies become standard of care
Cancer detection
Source Razavi P et al ldquoPerformance of a high-intensity 508-gene circulating-tumor DNA (ctDNA) assay in patients with metastatic breast lung and prostate cancerrdquo Journal of Clinical Oncology 2017 httpswwwascoorgabout-ascopress-centernews-releasesliquid-biopsy-tests-people-cancer-expert-review Oncology Roundtable d interviews and analysis
1) Circulating tumor DNA
Tumor DNA in the bloodstream detects
cancer or used for molecular testing
Blood vessel
ctDNA1
Blood cell
ctDNA extracted
Sequenced and analyzed
Cancer mutations detected and
actionable next steps taken
1
2
3
Case in Brief GRAIL Inc
bull Silicon Valley startup developing blood test to
detect cancer in asymptomatic people that reads circulating tumor DNA (ctNA)
bull In an early study 90 of advanced cancer patients receiving the test had at least one mutation detected in tumor tissue that was also
detected in the blood
Not ready for primetime
ldquoLike all new things in medicine the use of
ctDNA assays in routine cancer care requires
evidence of clinical utility At present there is
insufficient evidence of clinical validity and
utility for the majority of ctDNA assays in
advanced cancerhelliprdquo
Daniel F Hayes MD FACP FASCOASCO expert review
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
41
Something even less invasive A breathalyzer
Commercialization of nanoscale sensor technology in the works
Source Nakhleh et al ldquoDiagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Moleculesrdquo ACS Nano 2017 Oncology Roundtable interviews and analysis
Breath analysis process
Diseases detected by
breathalyzer test
Patient breathes into breathalyzer device with artificially intelligent nanotechnology sensors
86
Sensors detect and quantify pre-identified organic compounds in exhaled air
accuracy of disease detection and discrimination
between diseases in tests to date
No injections or blood draw
Instant results
Lower cost than traditional blood tests
bull Lung cancer
bull Colorectal cancer
bull Head and neck cancer
bull Ovarian cancer
bull Bladder cancer
bull Prostate cancer
bull Kidney cancer
bull Gastric cancer
bull Crohnrsquos Disease
bull Ulcerative Colitis
bull Irritable Bowel Syndrome
bull Idiopathic Parkinsonrsquos
bull Atypical
Parkinsonism
bull Multiple Sclerosis
bull Pulmonary Arterial
Hypertension
bull Pre-eclampsia
bull Chronic Kidney Disease
Benefits of breathalyzer
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
42
Widespread use of biomarker testing
99 of physicians report using tests for some of their patients
Tumor biomarker testing
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
46
30
17
18
19
15
9
5
22
35
44
36
9
10
17
17
6
12
14
25
Liquid biopsy
Broad next-generationgenome
sequencing
Multigene panel
FDA-approvedcompaniondiagnostic
0 1-10 10-25 25-50 gt50
Percent of physicians using biomarker tests
n=200
Percent of physiciansrsquo patients receiving each test
Mean percent of patients receiving
each test
30
24
17
10
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
43
Struggling to keep up
Challenges evaluating test quality predicting reimbursement
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology-Trends2018_Genentech_Oncology_Trend_Reportpdf Kuderer N et al ldquoComparison of 2 Commercially Available Next-Generation Sequencing Platforms in Oncologyrdquo JAMA Oncology July 2017 httpsjamanetworkcomjournalsjamaoncologyfullarticle2593039 CMS ldquoDecision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer httpswwwcmsgovmedicare-coverage-databasedetailsnca-decision-memoaspxNCAId=290 Oncology Roundtable interviews and analysis
1) Nine patients received both Guardant360 and FoundationOne tests
next-generation sequencing
tests approved by the FDA at
end of 2018
Comparison of two commercially
available NGS platforms1
5
22 of alterations
identified by both
tests were
concordant
25 of drugs were
recommended for
the same patients
by both platforms
Currently covers
bull Patients with recurrent metastatic or advanced-stage disease
bull Tests with FDA approval as companion diagnostic and indication for use in patientrsquos
cancer type
Does not cover
bull FDA-approved tests detecting germline BRCA
mutations in early-stage patients
CMS to revisit national coverage determination
on NGS testing
Percent of managed care organizations with
policies to cover biomarker tests
13
22
38FDA-approved
companion diagnostics
Multi-gene panels
Whole-exome
sequencing
n=100
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
44
A win-win for cost and quality
Two promising innovations aim to limit use of ineffective treatment
Source Landhuis E ldquoTumor lsquoorganoidsrsquo may speed cancer treatmentrdquo ScienceNews December 17 2018 Boston University Biomedical Optical Technologies Lab httpwwwbuedubotlab Oncology Roundtable interviews and analysis
Tumor tissue removed
Use of organoids in drug
screening and selection
Grown in a lab to create 3D organoids
Multiple cancer drugs tested on each organoid revealing which drug the tumor will respond to
Multiscale imaging to monitor
real-time tumor response
Case in Brief BOTLab
bull Researchers at Boston Universityrsquos
Biomedical Optical Technology Lab (BOTLab)
develop wearable probe to monitor breast
tumors
bull Received $100000 in funding from American
Cancer Society and Global Center for Medical
Innovation to bring technology to market
Near-infrared
spectroscopy
bull Measures tumorrsquos hemoglobin metabolism water and fat level
bull Allows for real-time monitoring of tumor
response to chemotherapy
number of PubMed results for ldquocancer
organoidrdquo articles published between
January 2016 and March 2019
877
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
45
A shifting landscape of cancer drugs
Treatment innovations
Source Mullard A ldquo2016 FDA drug approvalsrdquo Nature Reviews Drug Discovery 2017 Aitken M ldquoMedicines Use and Spending in the US A Review of 2015 and Outlook to 2020rdquo IMS Institute for Healthcare Informatics 2016 ldquo2016 Profile Biopharmaceutical Industryrdquo PhRMA 2016 ldquoWhat Are Biologics Questions and Answersrdquo US Food amp Drug Administration 2015 ldquoNCI Dictionary of Cancer Termsrdquo NIH National Cancer Institute ldquoWhat Is Gene Therapyrdquo NIH 2017 Oncology Roundtable interviews and analysis
Biologics Complex (and typically high-cost) drugs manufactured from living microorganisms plants or animal cells
Gene therapy Using genes to treat or prevent disease by
bull Replacing a mutated gene with a
healthy copy
bull Inactivating a mutated gene
bull Inserting a new gene into cells
Immunotherapy A biological therapy that stimulates or suppresses the immune system (or immune cells) to help
the body fight disease (eg cytokines vaccines checkpoint inhibitors)
CAR T Chimeric antigen receptor (CAR) T-cell therapy an emerging type of immunotherapy that reprograms genes of
T cells to recognize and kill diseased cells
1
2
Two ways to target tumors more precisely
Mechanism Outcome
Drug binds to specific bio-molecules or
cell types
Genes inserted or altered to combat disease
Eradicates source of errant signaling mechanism
Influence malfunctioning cellular pathways
of drugs approved in 2018 were personalized
40expected increase in cancer immunotherapy market from 2018-2024
300number of CAR T trials in the US in 2018
144
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
46
Changing the treatment paradigm
Keytruda is first with FDA approval based on tumor genetics not location
Source Le D et al ldquoMismatch repair deficiency predicts response of solid tumors to PD-1 blockaderdquo Science 2017 Kolata G ldquoCancer Drug Proves to Be Effective Against Multiple Tumorsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
Case in Brief Keytruda
(pemprolizumab)
bull Checkpoint inhibitor that targets
the PD-1PD-L1 cellular pathway
bull First approved drug for use
against all tumors that share a
common genetic mutationmdash
microsatellite instability-high
(MSI-H) or mismatch repair
deficient (dMMR)mdashregardless of
location in the body
Identifying shared gene mutation across tumor types
Identified tumor mutations (MSI-H andor dMMR) that prevent tumor from repairing DNA
4of cancer patients have the genetic mutation susceptible
to pembrolizumab
$13Kper-month cost of Keytruda infusion
53of tumors with radiographic evidence showing
tumor shrinking
21of patients with tumors completely eliminated
In phase I study of other anti-PD-1 agent nivolumab found an ldquoexceptional responderrdquo where colon tumor disappeared
Researchers analyzed patientrsquos cancer cells and found a plethora of mutated genes and abnormal proteins
1
2
3
4 Studied patients with 12 different cancers that shared the MSI-H andor dMMR mutation to test clinical efficacy of pemprolizumab found tremendous response rates
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
47
Use of immunotherapy skyrocketing
Cost continues to be providersrsquo biggest barrier
Source Abt Associates ldquoEvaluation of the Oncology Care Modelrdquo Performance Period Onerdquo December 2018 Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 Tang J et al ldquoThe clinical trial landscape for PD1PDL1 immune checkpoint inhibitorsrdquo Nature Reviews Drug Discovery no 17 (2018) 845-855 Oncology Roundtable interviews and analysis
72
33
25
19
Challenges associated with
checkpoint inhibitor-based therapies
n=110 cancer programs
Tumor site 2014-2015 2016-2017
Lung 14 305
Head and neck 09 216
Kidney 05 441
Melanoma 564 824
Cost
reimbursement
Availability
access to drugs
Knowledge
of new
drugs
Comfort
managing side
effects
Percent of Medicare cancer patients
receiving checkpoint inhibitors
increase in the number of active trials evaluating checkpoint inhibitors from 2017 to 2018
33
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
48
CAR T generates exciting results for liquid tumors
Leukemia drug is the first gene therapy approved by FDA
Source ldquoFDA approval brings first gene therapy to the United Statesrdquo US Food amp Drug Administration 2017 Kolata G ldquoNew Gene-Therapy Treatments Will Carry Whopping Price Tagsrdquo The New York Times 2017 Oncology Roundtable interviews and analysis
1) Within three months
83remission rate following
treatment with Kymriah1
$475Kcost of one-time
Kymriah injection
Promising resultshellip hellipat eye-popping cost
Reprogramming the immune system
with CAR T-cell therapy
T cells extracted from patient
Genes sent to and manipulated in lab
Engineered cells infused into patient
T cells trigger death of cancerous cells
FDA-approved CAR T-cell
therapies
Novartisrsquos Kymriah
bull Approved for treatment of adolescent
acute lymphoblastic leukemia
bull Priced at $475000
Kite Pharmarsquos Yescarta
bull Approved for treatment of aggressive
B-cell non-Hodgkin lymphoma
bull Priced at $373000
Select toxicities
bull Delirium
bull Anaphalaxis
bull Autoimmune
response
bull Neurologic adverse
effects
bull Cytokine release
syndrome
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
49
Underscoring the systemrsquos inability to keep up
Current reimbursement doesnrsquot come close to covering provider costs
Source Swetlitz I ldquoHospitals are saving lives with CAR-T Getting paid is another storyrdquo STATNews March 12 2019 httpswwwstatnewscom20190312hospitals-arent-getting-paid-for-car-tutm_source=STAT+Newslettersamputm_campaign=c6a2eb5301-Cancer_Briefingamputm_medium=emailamputm_term=0_8cab1d7961-c6a2eb5301-151230725 Oncology Roundtable interviews and analysis
1) Inpatient Prospective Payment System
Progression of CAR T reimbursement by CMS
2017
bull FDA approves Kymriah and Yescarta
bull Experts estimate total costs of $500K-1M including
therapy hospitalization supplies and labor
2018
bull CMS sets Medicare part B reimbursement rates for the
drugs at $500K and $400K respectively
bull CMS sets 2019 IPPS1
payment at maximum of $186500 per case
2019
bull CMS proposes increasing new technology add-on
payment to total of ~$243K in inpatient setting
bull Includes proposal that providers have to enroll beneficiaries in CMS-approved
registry for two years
ldquoThe CAR T story is an example of how government
programs often fail to keep pace with innovationrdquo
Seema Verma
CMS Administrator
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
50
Stressing the importance of real-world data
Opportunity for pharma and providers to work together
Source Genentech ldquo2018 Genentech Oncology Trend Reportrdquo April 2018 httpswwwgenentech-forumcomcontentdamgenemanagedcareforumpdfsOncology -Trends2018_Genentech_Oncology_Trend_Reportpdf Oncology Roundtable interviews and analysis
7
4
4
9
8
11
26
15
6
44
40
34
15
33
45
Strongly disagree Somewhat disagree Undecided
Somewhat agree Strongly agree
Real-world data are essential for sound coverage and reimbursement decisions
about cancer treatments
Managed care organizationsrsquo perceptions on real-world data in
coverage determinations
n=100
Patient-reported outcomes and quality-of-life surveys in real-world settings are
important in coverage determinations
Within the next five years products unable to show benefit in real-world settings within a reasonable timeframe will lose coverage
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
51
Oncology Roundtable insight
Clinical innovations will force programs to weigh
two new investmentsmdashthe cost of the innovation
and the infrastructure needed to support it
While many programs want to immediately start
implementing clinical innovations there are two
financial consequences of doing so First
reimbursement is lagging behind scientific advances
Programs need to carefully evaluate and contribute to
the evidence base supporting innovations Second
programs need to consider new organizational
investments such as enhanced lab capabilities
molecular expertise clinical decision support patient
support and data management
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
52
Breaking traditional health behavior patterns
Oncology still referrals driven but patients playing more active role
Pressure 3 Patient experience
Source Oncology Roundtable interviews and analysis
Rising expectations
for service
Increasing access to health
care information
bull Access to and use of the Internet now nearly ubiquitous
bull More organizations
publishing health care cost and quality data
bull Growth in online communities and availability of patient
reviews
bull Patients gaining experience with different-in-kind providers (eg Walgreens
MinuteClinic)
bull Nature of patient-physician relationship changing
patients more skeptical and questioning
1 2
Patients becoming more influential decision-makers
Growing price
sensitivity
bull Rising health care costs
bull Patients shouldering larger portion of health care costs
bull Patients increasingly
including costs in-network coverage when selecting providers
3
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
53
At the heart of everything you do
Majority of programs investing in patient-centered services
Source 2016 Cancer Support Services Volumes Staffing and Operations Benchmarks Oncology Roundtable interviews and analysis
Sample cancer program
investmentsPressures forcing programs to revisit
investment strategy
93employ clinical
navigators
77offer exercise
therapies
76employ dietitians
1
2
3
4
Mounting budget pressure makes it
difficult to fund non-reimbursed services
Growing patient population means
more demand for services
Heightening workforce shortages forces
programs to evaluate capacity and demand
Increasing competition makes it critical to
differentiate program for patients physicians
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
54
330 310
240
120
Feature 1 Feature 2 Feature 3 Feature 4
Figuring out what matters most to patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
Cancer Patient Experience Survey
Questions included
bull Demographics (eg age sex tumor type stage race)
bull Priorities and behaviors when choosing a provider and
receiving care
bull Preferences for survivorship support services
1201 patients and survivors
diagnosed in last five years
Advantages of MaxDiff surveys
Allow researchers to
understand the magnitude
of difference between
ranked attributes
Force respondents to
choose between attributes
preventing ceiling effects
1
2
Interpreting MaxDiff results
Utility scores for the set of attributes sum to 100 Utility scores
represent the relative value of each attribute
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
55
What matters when selecting a provider
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
08
14
16
29
31
34
48
49
55
65
108
111
123
133
175Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality (eg survival rates)
In-network for my insurance
Accreditation (eg Commission on Cancer)
Patient support services
Costs Irsquom responsible for
Reputation (eg US News ldquotop doctorsrdquo report)
When deciding where to go for care which feature is most and least important to you
n=1201 cancer patients
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
56
Cancer patients doing their research
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
3
3
4
4
5
7
12
15
19
23
33
34
81
Other
Community website forum or blog
Employee health navigation site
General ratings website
I did not consult any resources
Social media website
Medicare or other government website
Medical-focused ratings website
Major search engine
Cancer-specific website
Family friends or colleagues
My health insurance company
Cancer center physician practice website
My doctor
Which of the following resources did you use when deciding where to go for your cancer care
n=1201 cancer patients
48 of cancer patients searched
online when deciding where
to go for care
21average number of sites
consulted by patients
searching online
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
57
Itrsquos not enough just to attract patients
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
3
4
6
7
10
13
13
17
18
20
23
28
I wanted to spend less money on my care
I couldnt get appointments when I needed them
I wanted a nicer facility and better amenities
I wanted access to clinical trials
I wanted better support services
They could not provide the treatment I needed
Friends or family recommended a different provider
I wanted a location that was closer to my homework
I found a higher quality program
I wanted better customer service
I wanted moredifferent treatment options
I found a different doctor who specializes in my care
Why did you change cancer care providers
n=127 cancer patients
11 of cancer patients said they changed care
providers at some point during their treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
58
Patient priorities for services and amenities
Source 2019 Cancer Patient Experience Survey Oncology Roundtable interviews and analysis
15
21
23
23
30
33
35
35
44
45
46
54
59
67
71
90
92
109
110
All of my care takes place in one building
Specialized symptom management
Multidisciplinary care clinics
Nurse phone line for help with symptoms
Survivor support services after finishing treatment
Patient education services
Help scheduling and coordinating my appointments
Support services for my family
Across treatment which services would have been most valuable and least valuable to you
n=1201 cancer patients
Online portal to view test results contact care team
Help with nutrition
Extended hours of operation
Complementary and alternative medicine
Access to genetic testing and counseling
Parking that is convenient and affordable
Free or discounted transportation
One point of contact to help me understand my care
Financial counseling
Social and mental health services during treatment
Religious and spiritual services
Mean utility scores
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
59
Going above and beyond
Source True W Modernizing the Patient Experience Through Technology The Experience Enginerdquo ACCC October 2 2018 httpswwwaccc-cancerorgacccbuzzblog-post-templateaccc-buzz20181002modernizing-the-patient-experience-through-technology-the-experience-engine WFTV ldquolsquoBetty the robot helps Orlando Health UF Health Cancer Center patientsrdquo January 9 2018 httpswwworlandohealthcancercomcontent-hubbetty-the-robot-helps-orlando-health-cancer-center-patients Oncology Roundtable interviews and analysis
ldquoHenry Ford looks to boost patient
experience with technologyrdquo
ldquorsquoBetty the robot helps Orlando Health
UF Health Cancer Center patientsrdquo
Working with The Experience Engine (TE2)
a company that has worked with cruise ships
and Disney to modernize customer experience
In testing phase to determine patient
experience and efficiency impact of
using a robot to assess patient distress
ldquoWe want to use this to do whatever we possibly can to remove any ounce of worry or stress that is not medical-relatedrdquo
Steven Kalkanis MD Medical Director Henry Ford Cancer institute
ldquoMaybe a little R2D2 a little Baymax if yoursquove seen Big Hero 6 Those are a few of the inspirationsrdquo
David Metcalf PhD Institute for Simulation and Training University of Central Florida
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
60
Oncology Roundtable insight
The costs of patient acquisition and retention
are going up
Given increased pressure to differentiate your cancer
program and retain patients cancer programs will need
to weigh investments in marketing improving operations
and developing new services While this is not new
terrain for oncology providers it will require additional
investment in understanding and gaining insight into
what your market needs and wants in a cancer provider
Source Oncology Roundtable interviews and analysis
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
ROAD MAP61
A growing margin problem1
2 Three emerging cost pressures
3 Driving innovation
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
62
Facing our new cost pressures
Thoughtful investment is integral to effective cancer program strategy
Source Oncology Roundtable interviews and analysis
Patient
experience
Value-
based careChanging payment
models force providers
to live in prolonged
period of investment
experimentation
Emerging health care
consumers create
urgency to invest in
expensive service
enhancements
Evolving diagnostics and
treatment options spur investment
despite unclear reimbursement
Clinical innovations
Provider
strategy
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
63
A holistic view
Source Oncology Roundtable interviews and analysis
Staffing
Drugs and supplies
Capital investments
Service utilization
Immediate cost priorities Emerging cost priorities
Value-based care
Clinical innovations
Patient experience
1
2
3
Key to ensuring
financial sustainability
Key to achieving
market advantage
Cancer providersrsquo financial priorities
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
64
What wersquore all aiming for
Intermountainrsquos innovation efforts drives improved outcomes
Source Intermountain Healthcare Salt Lake City UT Haslem D et al ldquoPrecision oncology in advanced cancer patients improves overall survival with lower weekly healthcare costsrdquo Oncotarget February 2 2018 Oncology Roundtable interviews and analysis
Provider selects treatment based on available evidence
Provider orders genomic test on EHR through Syapse platform
Provider receives test results from Syapse in easy-to-understand format
Syapse prompts provider to report patient outcomes
Intermountain analyzes outcomes data across patients
Intermountainrsquos clinical decision
support platform
Outcomes data they will track includes survival adverse events
hospitalED visits therapies received
imaging results and costs
Plan to include outcomes data at point of care allowing providers to see
how similar patients performed on therapies
Intermountain incorporates findings into internal treatment guidelines
69lower costs in last three months of life for patients on targeted treatment
2xgreater overall survival for patients on targeted treatment
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
65
Building a foundation for success
In-depth discussion of your top priorities
bull How patients make trade-offs when choosing providers
bull Where programs are most vulnerable to patient leakage
bull Innovative strategies to drive engagement and reduce turnover for key team members
bull Lessons to develop data-driven staffing models
bull Guidance on managing political dynamics and working effectively with system and site leaders
bull Frameworks for making principled decisions for investment
bull Tactics to align strategy and care delivery across sites
What matters most to cancer
patients
Building the engaged
oncology workforce
How to survivemdashand
thrivemdashin a system
Networking reception
Get to know your peers through targeted group
discussion
Optional tools workshop
Explore data from our 2019 Cancer Patient
Experience Survey
Implementation tools
Use complementary tools and resources to implement change
at your program in follow up
Additional features of this yearrsquos Oncology Roundtable National Meeting
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler
copy2019 Advisory Board bull All rights reserved bull WF1088267-a 0701
LEGAL CAVEAT
Advisory Board has made efforts to verify the accuracy of the information it provides to members This report relies on data obtained from many sources however and Advisory Board cannot guarantee the accuracy of the information
provided or any analysis based thereon In addition Advisory Board is not in the business of giving legal medical accounting or other professional advice and its reports should not be construed as professional advice In particular members should not rely on any legal commentary in this report as a basis for action or assume that any tactics described herein would be permitted by applicable law or
appropriate for a given memberrsquos situation Members are advised to consult with appropriate professionals concerning legal medical tax or accounting issues before implementing any of these tactics Neither Advisory Board nor its officers directors trustees employees and agents shall be liable for any claims liabilities or expenses relating to (a) any errors or omissions in this report whether caused
by Advisory Board or any of its employees or agents or sources or other third parties (b) any recommendation or graded ranking by Advisory Board or (c) failure of member and its employees and agents to abide by the terms set forth herein
Advisory Board and the ldquoArdquo logo are registered trademarks of The Advisory Board Company in the United States and other countries Members are not permitted to
use these trademarks or any other trademark product name service name trade name and logo of Advisory Board without prior written consent of Advisory Board All other trademarks product names service names trade names and logos used within these pages are the property of their respective holders Use of other company trademarks product names service names trade names and logos or
images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services or (b) an endorsement
of the company or its products or services by Advisory Board Advisory Board is not affiliated with any such company
IMPORTANT Please read the following
Advisory Board has prepared this report for the exclusive use of its members
Each member acknowledges and agrees that this report and the information contained herein (collectively the ldquoReportrdquo) are confidential and proprietary to Advisory Board By accepting delivery of this Report each member agrees toabide by the terms as stated herein including the following
1 Advisory Board owns all right title and interest in and to this Report Except
as stated herein no right license permission or interest of any kind in this Report is intended to be given transferred to or acquired by a memberEach member is authorized to use this Report only to the extent expressly authorized herein
2 Each member shall not sell license republish or post online or otherwise this
Report in part or in whole Each member shall not disseminate or permit the use of and shall take reasonable precautions to prevent such dissemination or use of this Report by (a) any of its employees and agents (except as stated below) or (b) any third party
3 Each member may make this Report available solely to those of its employees
and agents who (a) are registered for the workshop or membership program of which this Report is a part (b) require access to this Report in order to learn from the information described herein and (c) agree not to disclose this Report to other employees or agents or any third party Each member shall use and shall ensure that its employees and agents use this Report for its
internal use only Each member may make a limited number of copies solely as adequate for use by its employees and agents in accordance with the terms herein
4 Each member shall not remove from this Report any confidential markings copyright notices andor other similar indicia herein
5 Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents
6 If a member is unwilling to abide by any of the foregoing obligations thensuch member shall promptly return this Report and all copies thereof to Advisory Board
Oncology Roundtable
Project DirectorDeirdre Saulet
sauletdadvisorycom
202-568-7863
Program Leadership Alicia DaughertyShay Pratt
Design Consultant Hailey Kessler