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Alternate Payment Methodologies: Building and Costing Care Bundles
Mark Sobczak, MDFox Chase Cancer CenterPhiladelphia, PA
Moderator
Speakers
• Constantine Mantz, MD, 21st Century Oncology
• Therese Mulvey, MD, SouthCoast Health System
• Khanh Nguyen, PharmD, Hill Physicians Medical Group
• John Steiner, Esq., Cancer Treatment Centers of America
Alternate Payment Methodologies: Building and Costing Care Bundles
John Steiner, Esq.Chief Compliance & Privacy Officer and Associate General Counsel, Cancer Treatment Centers of America
Alternate Payment Methodologies: Building and Cost Care Bundles
Presented by: John Steiner, Esq.Chief Compliance & Privacy Officer and Associate General Counsel
Bundled Price for Evaluation of Patients with Breast, Lung, Colorectal and Prostate Cancers
Premise: Empower patients (consumers) to control
personal healthcare decisions; decrease reliance on government
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CTCA Vision for a Bundled Price Evaluation
Allow a consumer – driven oncology marketplace to thrive
Consumer choice based on informed judgments of the value of providers’ services
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Consumer Judgments
Require transparency of:– Product quality– Convenience– Consistency of delivery– Price
A bundled evaluation is an important step for empowering consumers
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Our Patient Empowered Care (PEC) Model
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Value- based cancer diagnostics and treatment plan.
Objective: Provide payers and patients with a complete, comprehensive diagnostic evaluation and a personalized treatment plan within 3 to 5 days at a set price.
In 2012, limited to the diagnostic and treatment planning phase of cancer care vs. treatment phase
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Limitations on Set Fee Pricing
Participating patients in the bundled price evaluation must be identified in advance (no retro-active application of set fee pricing)
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Excluded Services
Bundle excludes treatment of co-morbid conditions and emergencies due to other medical conditions that may require treatment while patient is at a CTCA facility for an evaluation
e.g. Diabetes, Myocardial Infarction – and their sequelae
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Lung, Breast, Prostate, Rectal and Colon cancers.
Components:– Medical Oncologist Consultation– Imaging / Pathology Services
Medically necessary, per the medical oncologist, to provide an appropriate evaluation
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Nutritional Consultation
– Evaluation by a registered dietitian with experience serving cancer patients
– Related lab tests and a plan to keep the patient well nourished, prevent malnutrition, rebuild body tissue and support immune function while ongoing treatment
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Naturopathic Consultation
– Evaluation by a naturopathic provider certified in oncology
– Development of a plan to support normal metabolism, boost the immune system and alleviate treatment-related side effects
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Mind-Body Medicine Consultation
– Licensed health professional experienced with help in cancer patients cope with their disease, regain and maintain a sense of control of their lives and treatment
– Specialist Consultations (as needed)
Radiation oncologists / Surgeons /
Pain management / Interventional Pulmonologists/ others
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Treatment Plan Development and Review
– Comprehensive, integrated treatment plan tailored to the patient’s needs; developed by the patient’s oncologist and care team working together at the patient’s side.
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Also included:
– Consultations with allied health professionals, as appropriate, e.g. rehabilitation therapy, chiropractic care, acupuncture and pastoral care
– Transportation, lodging and meals for patient and companion
– Care management, patient relations, patient scheduling and travel planning
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Recap
Bundled price for evaluation of Breast, Lung Colorectal and Prostate CancersPatient empowered care/consumer choice based on informed value judgmentsComposite of professional and facility services associated with a diagnostic evaluation and integrated treatment plan
© 2011 Rising Tide
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Alternate Payment Methodologies in Oncology: Building and Costing Care Bundles
Therese M. Mulvey, MDSouthcoast Centers for Cancer CareFairhaven, MA
More than medicine.
Stage IV Lung Cancer Patient Study
Therese M Mulvey, MD
Southcoast Centers for Cancer Care
Fairhaven, MA
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Southcoast Health
• 900 in patient bed system, three hospitals and 22 ambulatory sites.
• Two Cancer Centers• 1500 new cases per year to SCCC• Seven medical Oncologists• Three Radiation Oncologists• Two private groups• Self Insured System of 6800 nemployees
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• Determine the number of admissions in the last six months of life in this vulnerable population.
• Determine the AD status, hospice utilization and therapy delivered to this group.
• Determine if a TME could be calculated that could provide wrap around care for this group of patients to prevent admissions.
Lung Study
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Overview
• 103 Records reviewed from yrs 2009 – 2013.• Non small cell and small cell patients.• All Patients over age of 65.
– Average age 75.– All patient have died.
• Median OS for all patients = 4 months.• Median admission number 3.1 in last 6 months of life.• 65% of admissions occur over the weekend.• 16% died in Hospital.• 82% had AD documented in chart before death.• 90% of AD were obtained during a hospital admission 10% as
an outpatient.
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OS for Stage 4 Lung Cancer patients over 65
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Treatment Modality and Admissions
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Admission Rates
Excluding initial admission for diagnosis
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Most Common Admission Diagnoses
• 0-3 months- symptoms of cancer.
– Pain, dyspnea, hemoptysis, seizure, etc.
• 3-6 months- equal symptoms of cancer or side effects of therapy.
– Neutropenia, nausea, vomiting, diarrhea, salt wasting, etc.
• 6-24 months- equal side effects of therapy and symptoms of cancer.
• Equal numbers of pulmonary emboli/DVT and unrelated causes in all groups.
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EOL State at Last Admission
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Days on Hospice
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Median days on Hospice per Survival Group
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All Oncology Patients SCCC
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• 2014 addition of outpatient palliative care consults.
• This service was added despite an anticipated loss in revenue vs expense.
• Integrated palliative care physician into weekly rounds.
• Integration of palliative care VNA team and hospice RNs to rounds and weekly MDC.
• Addition of a triage nurse to call each stage IV lung patient every Friday to assess symptoms.
• Financial Quality Incentive to meet QOPI standard of AD before third outpatient visit in Stage IV non small cell lung cancer patients.
Palliative Care Project
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Palliative Care
• 2014 data:– 21 patients stage IV lung cancer, age over 65.– 13 had Palliative Care consults.– 5 not offered palliative care/ 3 refused– 9 admissions: 4 for treatment effect, 5 for
symptoms of disease.• 4/5 admissions for symptoms were not
actively followed by the palliative care team.– 20/21 had AD prior to admission.
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• We set out to determine a TME for this population of patients who had a high symptom burden and excessive numbers of admissions.
• Cost analysis revealed a high net reimbursement rate in the FFS model.
• TME for other diagnoses (CHF, Pneumonia) fell well below the net margin on this subgroup of patients.
• The cost of the “wrap around” services outpaced the projected TME.
Cost Decision Analysis
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Summary• Two thirds of all individuals diagnosed with a Stage IV Lung cancer
age 65 or older lived 6 months or less with a median survival of 4 months.
• Symptom burden is high for this group of patients and is the most common cause of admission across all survival groups.
• Palliative XRT in the 0-3 mo OS group was the primary treatment without impact on OS.
• 38% of all patients referred to hospice had a LOS of 1 -5 days.
• 74% had a hospice LOS < 20 days
• Treatment with sequential or concurrent Chemo/XRT increased toxicities and hospital admissions for side effects of therapy.
• Overall survival in this group mirrored other community cancer program data.
• Documented EOL discussions as part of a comprehensive palliative care program appeared to reduce admissions in the 2014 data.
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Summary
• In a fee for service model there is no incentive to change the status quo.
• A TME model will need to account for the high symptom burden of the disease, progression despite therapy in the last six months of life and the costs associated with a comprehensive palliative care program.
• Palliative care as a stand alone program as it currently exists in a FFS setting loses money to a health system and the incentive to fully implement this program in the community is a barrier to implementation.
Alternate Payment Methodologies: Building and Costing Care Bundles
Constantine Mantz, MDChief Medical Officer21st Century Oncology
Learning Objectives• Describe the design and function of the first near-
comprehensive episodic payment system for radiation oncology between a provider and a major commercial payer
• Discuss its clinical and administrative advantages from the perspectives of patient, provider and payer
• Project use of current system as a basis for more comprehensive payment reform in oncology
Starting Points• Fee-for-service payments create widespread
inefficiency• payers spend large sums to create and enforce guidelines• providers devote substantial resources to ensure proper
authorizations and billings
• Measuring quality is particularly elusive in oncology• disease and toxicity outcomes become manifest over years• attribution of outcomes is not often direct
• Radiation oncology’s technologic focus creates a large number of clinical decision-making branch points difficult to reduce to guidelines
Conceptual FrameworkWhy providers?•Physicians are in the best position to develop the payment models that will promote care quality and efficient resource utilization•Ancillary Points:
• flexibility: to allow for appropriate latitude to exercise clinical judgment and technical skill on a per-case basis
• risk delegation and accountability: to separate ‘insurance’ risk from ‘performance’ risk
• operational efficiencies: to reduce existing administrative and direct practice costs that do not contribute to care quality; to improve revenue cycles times and predictability
Conceptual FrameworkWhy insurers?•Potential Advantages
• discounting• operational simplicity• clinical quality basis and performance reporting
•Remaining Challenges• legacy claims processing systems• internal customer and product alignment• risk adjustments, limits and exclusions, shared savings
Our Goals• Limit to radiation oncology• Build evidence-based/consensus-based clinical
pathways for all radiation oncology cases• Thoroughly understand our own cost accounting • Develop simple mechanism for recognition of cases
eligible for episodic payment• Continue FFS claims processing on both ends
(provider and insurer)• Later, include quality metrics reporting based on
specialty society consensus recommendations for process and outcomes as they are established
Episodic Payment Development
Episodic Payment Implementation
Conclusions• We have successfully launched and operated under an
episodic payment model for radiation oncology • Resource utilization and physician prescribing behaviors
remained > 98% compliant to the recommended treatment technologies and number of services modeled in each diagnosis group
• Press Ganey patient satisfaction surveys administered before and after bundle implementation demonstrated consistently high overall satisfaction with a statistically significant improvement in ‘Insurance Experience’ domain satisfaction
• We view our effort as a bottom-up approach, gathering development and operational know-how within a set of services we understand before participating in more comprehensive payment reform
Alternate Payment Methodologies: Building and Costing Care Bundles
Khanh Nguyen, PharmDDirector, Clinical Support Hill Physicians Medical Group
Oncology Case Rate (OCR)Payment Reform Example
Khanh Nguyen, Pharm.D.Director, Clinical Support
Hill Physicians Medical Group
Hill Physicians Medical GroupIndependent Physician Association founded in 1984Provider network: 3,800 providers and consultants
980 Primary Care 2,260 Specialists (170 Oncologists)
Service the Northern California area 300,000 Members 5 Regions - 9 Counties
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Oncology Case Rate (OCR)Bundled Payment System
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OCR Cancer Cohorts:Diagnosis Group by Cancer Type
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Cohort
Cancer TypeTotal Unique
Patients, 2010-2014 YTD
1 Colon & Rectum 116
2 Lung 136
3 Breast (female) 287
4 Ovary and other Uterine Adnexa 23
5 Prostate 41
6 Malignant Neoplasm of Other/Unspecified Sites 50
7 Malignant Neoplasm of Lymp/Hema Tissue 169
8 Other Malignant Neoplasm 158
9 Diseases of Blood & Blood-Forming Origin 27
Total Unique Patients 1,007
Quality Management Bonus ProgramProgram encompasses 3 domainsClinical measures are subject to audit and chart reviewsPerformance dashboards are shared with oncology groups
regularly
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Claims Process & Adjudication
Receipt of Monthly Payment
Patient Name DOB
Chemo Start Date SL Threshold SL Accumulation Cohort Case Rate SL FFS Post 3 Year Total
Smith, A 1/1/51 10/1/12 $70,000 $23,000 Breast $1,000 $500 $1,500
Operational Milestones Since OCR Implementation
Implementation of Oncology Case Rate Program May 2010 - program implemented for Sacramento practice Jan 2011 - program implemented for East Bay practice
Operational Milestones - annual enhancements of program for more efficient, effective & clinically appropriate system
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**Confidential**
Analytics & Reporting: FinancialFinancial Dashboards - measures yield between OCR & standard
fee-for-service payment methodologies
Analytics & Reporting: ClinicalCohort Monitoring – tracks patient’s progression in the 3 year program
Stop Loss Threshold: $74,000 Cumulative 3-Year Case Rate: $35,796
Summary
Over Stop Loss Threshold
Between Stop Loss Threshold and Cumulative 3-Year Case Rate
Below Cumulative 3-Year Case Rate
Total
# of Patients
10
12
68
90
% to Total # of Patients
11%
13%
76%
100%
Clinical Quality of Care60
OCR PerformanceASCO = American Society of Clinical Oncology
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Utilization Measure62
Inpatient Bed Days
Overall Survival Results63
OCR (N=128) vs. Control (N=146)p = 0.05
All 4 Cancer Cohorts (N=274){Esophageal, Pancreas, Lung, Stomach}
Survival Time (days)Day 0 = first day of chemotherapy
Su
rviv
al P
rob
ab
ilit
y
64Trends in Oncology PMPM Network vs. Sacramento OCR
Summary OCR practices demonstrated year-over-year
improvements in performance on ASCO clinical quality measures.
OCR practices out-performed standard FFS model in satisfaction and utilization metrics year-over-year.
OCR practices’ overall survival is non-inferior to the overall survival under a standard FFS model.
OCR practices continue to bend the cost curve over 3.5 years of program experience.
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