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Building the Oncology System of the Future Keynote Address:
Paul H. Keckley, Ph.D., Managing Director, Navigant Center for Healthcare Research & Policy Analysis
ASCO Envisions the Future of Oncology
Allen S. Lichter, M.D., FASCO Chief Executive Officer, American Society of Clinical Oncology®
What Did We Conclude?• We are in the throws of three simultaneous
revolutions in medicine and oncology that will play out over the next 10-15 years.
• Confronting any of these by themselves would be a daunting task.
• We must manage all three of them simultaneously.
The Three Revolutions
CancerPanomics Big data
Payment reform/Value
There is Likely a Fourth
CancerPanomics Big data
Payment reform/Value
Patient engagement
For today • In the interest of time, I will skip cancer panomics• It is a rich topic and we have many ideas in this
domain• Look at our report at asco.org to see them
From Cost to Value• Value as the driver of oncology practice - New
payment models that promote quality and value will prevail:o Routine quality measurement and improvement
become embedded firmly in practice.o Providers compensated according to ability to
demonstrate value and quality.o Public reporting of oncologist performance becomes
routine.
The Value Equation: Keeping Treatments Affordable
Improving the Value Equation• ASCO is convening the appropriate stakeholders to begin to
discuss how we could define and quantify “value”a. We have already published a paper outlining what we believe
are “meaningful outcomes” for new drugs to achieve.b. We now seek to group existing therapies into value groupings
to assist physician-patient communication.c. This could have a profound effect on shaping the conversation,
but it will not be easy to do. Stay tuned.
“Big Data” in Oncology• In the future, most new knowledge creation in
oncology will come from the analysis of “real world data”
• We will need to create a true “learning health system” for cancer care.
• ASCO has stepped up to this challenge
Origins of ASCO’s Interest
• We’ve lived in a world where research was in one side of the house and clinical care was on the other
• We now have an opportunity to link the two
• Classical research involving classic clinical trials will continue
• But we can also aggregate data from our routine clinical care and gain valuable insights from massive numbers of patients
Embedding Research into Practice
A Key Example:
To create a national system capable of collecting the EMR data from every single medical oncology encounter in the country.
We built a pilot project in breast cancer and confirmed feasibility.
Our Goal:
Our Test:
Big Data
19
Next Steps• Working with ASCO Board of Directors and other volunteer
leadership, we have defined a plan to further develop the project.
• We are in final negotiations with the partner we will use to develop the platform.
• We continue to garner philanthropic support and further engage
the clinical community; 12 Vanguard Practices have been recruited.
• We anticipate a product demo to be available at the 2015 ASCO Annual Meeting.
#4: Patient Engagement• The connected patient
• New devices
• Gathering PROs• Apps
Summary• The future of oncology is being shaped by at least
three simultaneous revolutions.• Cancer panomics will reshape how we diagnose,
treat, and follow our patients.• An emphasis on value- delivering and measuring
it- will replace a pure cost focus.• Big data holds the promise of rapidly accelerating
the learning cycle while helping us manage the “omics” and value issues.
Summary (cont’d)• We need to continuously monitor the changing
environment so we may shape it for the benefit of our patients.
• ASCO welcomes your participation in the effort. Working together, we will create the oncology care delivery system of the future.
Building the Oncology System of the Future
Lindsay Conway
Practice Manager, Oncology Roundtable
The Advisory Board Company
202-266-5845
Four Years Post-Reform, New Paradigm Finally Becoming Clear
Source: Health Care Advisory Board interviews and analysis.
The Retail Revolution
Medicare Reforms and the Transition to Risk
Coverage Expansion and the Rise of Individual Insurance
Activist Employers and the Primacy of Value
1
2
3
Major Themes Reshaping Provider Strategy
Disrupting Traditional Channels of Coverage
Source: Congressional Budget Office, “May 2013 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage,” available at: www.cbo.gov; Accenture, “Are You Ready? Health Insurance Exchanges Are Looming, “ 2013, available at: www.accenture.com; Kaiser Family Foundation, “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid,” April 2, 2014, available at: www.kff.org; Health Care Advisory Board interviews and analysis.
1) Based on number of lives falling into the “Medicaid expansion gap” in non-expansion states.
2) Based on the number of Medicare Advantage enrollees.
A Burgeoning Retail Market
Projected Size of the Potential Retail Market2018
1
2
Cadillac Tax Will Force Pay or Play Decision Starting in 2018
Source: Herring B and Lentz LK: “What Can We Expect from the ‘Cadillac Tax’ in 2018 and Beyond?” Inquiry, 2011, 48(4):322-37; Piotrowski J et al., “Health Policy Brief: Excise Tax on ‘Cadillac’ Plans,” Health Affairs, September 12, 2013, available at: www.healthaffairs.org; Mandelbaum R, “Why Employers Will Stop Offering Health Insurance,” The New York Times, March 26, 2014, available at: www.boss.blogs.nytimes.com; Health Care Advisory Board interviews and analysis.
How Long Can Employer-Sponsored Coverage Last?
Convert to Self-Funding
Hope for success in controlling total cost growth
Drop Coverage
Trade Cadillac Tax for employer mandate penalty
Shift to Private Exchange
Cap growth of employer contribution
Spectrum of Employer Options for Controlling Health Benefits Expense
Source: Health Care Advisory Board interviews and analysis.
Providers No Longer Insulated From Market Forces
Traditional Market Retail Market
Growing number of buyers
1
Proliferation of product options
2
Increased transparency
3
Reduced switching costs
4
Greater consumer cost exposure
5
Passive employer, price-insulated employee
Activist employer, price-sensitive individual
Broad, open networks Narrow, custom networks
No platform for apples-to-apples plan comparison
Clear plan comparison on exchange platforms
Disruptive for employers to change benefit options
Easy for individuals to switch plans annually
Constant employee premium contribution,
low deductibles
Variable individual premium contribution, high deductibles
Characteristics of a Traditional vs. Retail Market
Source: Health Care Advisory Board interviews and analysis.
Success Requires Winning at Two Points of Sale
Network Selection Care DecisionNetwork Assembly
Decision Processes Involved in Provider Choice
Being chosen by payers, employers, exchange operators, custom network
builders, and accountable physician entities to be offered as a network option
Being chosen by patients at the point of care
Being chosen by individuals during
enrollment
Secure Enrolled Lives Win Share of Volumes
1 2
Source: Health Care Advisory Board interviews and analysis.
Appeal to Network Assemblers
Clinical and Service Quality
Cost Geographic Reach and Clinical Scope
Achieve internal efficiency and implement population health model to achieve low total cost
Three Core Attributes
Achieve broad geographic footprint with complete set of clinical services to meet employer and individual needs
Achieve superior clinical quality and invest in consumer experience to differentiate from competitors
Source: Health Care Advisory Board interviews and analysis.
Appeal to Patients
“I have an urgent injury or illness that must be addressed immediately”
“I need to have a procedure done, but it’s not urgent—where do I go?”
“I want a relationship with a provider to manage my ongoing health needs”
• Low– to-mid acuity urgent care
• Emergency care
• Diagnostic procedures
• Surgical procedures
• Therapeutic procedures
• Preventative care
• Lifestyle management
• Chronic disease management
Emergent Care
Shoppable Procedures
Enhanced Management
Choosing Three Types of Products
Preliminary Data from 2014 Cancer Patient Experience Survey
Source: 2014 Oncology Roundtable Cancer Patient Experience Survey; Oncology Roundtable analysis.
How Cancer Patients “Shop” for Care
Doctor who specializes in my particular cancer
Technology and treatment options
Clinical quality
In-network for my insurance
Accreditation
Patient and support services
Cost
Ranking
When deciding where to go for your care, which feature is most and least important?n=602
Recommendation from my doctor
Recommendation from my family and friends
Location
Availability of appointments
Facility and amenities
Customer service
Availability of clinical trials
Source: Overland D, “CareFirst Medical Home Saves More in Second Year,” FierceHealthPayer, June 7, 2013, available at: www.fiercehealthpayer.com; Health Care Advisory Board interviews and analysis.
1) Per member per month.
Creating Cost-Conscious PCPs
Case in Brief: CareFirst BlueCross BlueShield• Not-for-profit health services company serving 3.4 million members in Maryland, D.C.,
and northern Virginia
• In 2011, launched PCMH program providing opportunities for virtual panels of 10-15 PCPs to earn bonuses based on quality and total cost metrics
• Provides PCPs with color-coded rankings of specialists based on risk-adjusted PMPM costs
Percent of eligible PCPs participating in PCMH program
80%
Members covered by PCMH program1M
Average pay increase for PCPs receiving bonuses
29%
“Virtual panel” of 10-15 PCPs
Panel shares in savings if risk-adjusted PMPM cost is below target
PMPM Cost Target
Actual PMPM Cost
Total cost target set by trending baseline risk-adjusted PMPM cost by average regional cost growth
CareFirst PCMH Total Cost Incentive ModelRisk-adjusted PMPM1 Cost
Total Cost Transparency Key to Referral Changes
Source: Health Care Advisory Board interviews and analysis.
Steering Care to Most Efficient Specialists
Specialists Color-Coded By Total Cost
PCP Virtual Panels
Employed Specialist A
(Red)
Employed Specialist B
(Yellow)
Independent Specialist C
(Green)
Hospital A Hospital B
Percent of panels earning bonuses, 201266%
Difference in risk-adjusted PMPM cost between top- and bottom-quartile PCPs
27%
Savings from PCMH program, 2012$98M
“We’re seeing that [the data] changes the patterns. Now there’s a general hubbub among the panels to see what their choices are, and what it costs them.”
Chet BurrellPresident & CEO
CareFirst BlueCross BlueShield
Forging the Path to the Future
35
Source: Oncology Roundtable interviews and analysis.
Innovation Drivers
Care Delivery Innovation
Clinical Innovation
Patient-Centered
Care
Targeted Treatment
Personalized Medicine
Clinical Innovation
• Prioritization of minimally invasive approaches
• Genomic medicine• Comparative effectiveness
research
Care Delivery Innovation
• Payment reform• Consumer demand• Cost pressure• Clinical integration
Path to Personalized Medicine Converging with Focus on Value
An Era of Experimentation
36
Numerous Approaches to Realigning Incentives
Source: Oncology Roundtable interviews and analysis.1) Fee-for-service.
Payment Models Piloted in Oncology
Complexity and Financial Risk
Fee Schedule Adjustments
Episode-Based Pay
Diagnosis/Treatment
Bundle
Shared Savings
Bonus payment for reaching pre-determined pathway compliance rate
Adjustments to payments to incent greater use of generics, or better payment rates in return for quality initiatives
Providers at risk for population; services billed FFS1 and providers share in savings if cost kept below pre-determined benchmark
Single payment to both hospital and physician for all services related to care delivered within pre-defined episode
One payment for select component of treatment, can include case management; remainder is FFS1
Pathway Compliance
Bonus
+
Enhancing Care Management to Reduce Costs
37
Source: Health Care Advisory Board, Playbook for Population Health Management, Washington, DC: The Advisory Board Company, 2013; Oncology Roundtable interviews and analysis.
Care Delivery Innovation
Keep patients healthy, loyal to the system
Prevent patients from becoming high-risk
Trade high-cost services for low-cost management
60%-80% of patients; any minor conditions are easily managed
15%-35% of patients; may have conditions not under control
5% of patients; usually with complex disease(s), comorbidities
Three Distinct Patient Populations and Care Strategies
Success Requires Risk Stratification
Different Goals for Different Populations
38
Source: Oncology Roundtable interviews and analysis.
Care Delivery Innovation
Keep patients healthy, loyal to the system
Prevent patients from becoming high-risk
Trade high-cost services for low-cost management
High-Risk Patients
Rising-Risk Patients
Low-Risk Patients
Three Distinct Population Strategies
• Cancer screenings• Smoking cessation counseling• Cancer prevention education• Genetic testing
• Distress screening and management• Systematic phone triage• Timely palliative care referrals• Advanced care planning
• Multidisciplinary clinics• Intensive patient navigation• Timely hospice enrollment• Caregiver support
Representative Cancer Program Initiatives
Key Takeaways
39
Source: Oncology Roundtable interviews and analysis.
1. In order to grow in the future, hospitals need to learn to compete at two points of sale. They must secure their position in narrow networks, and they must appeal to price-sensitive patients.
2. Cancer patients tend to be the least cost-sensitive and the least likely patient sub-group to “shop” for health care services. But as shopping for health care services becomes the norm, and cancer cost and quality data become more widely available, cancer patients will become more discerning – and demanding - consumers.
3. Although cancer patients tend to deprioritize costs when choosing a cancer care provider, referring physicians are increasingly steering their patients to lower cost specialists, putting pricing pressure on providers.
4. Multiple payers and providers are working to pilot new oncology payment models that promote a higher-value cancer care, but the early results are inconclusive. Cancer providers should expect ongoing experimentation with payment reforms across the next decade and may want to consider participating in a pilot in order to begin to build the competencies required to manage risk.
5. To keep costs down, providers must invest in care delivery innovations that proactively address patients’ medical and psychosocial needs to reduce complications, acute care episodes, and duplicative or unwanted health care services. One of the cornerstones to success is risk-stratifying patients and deploying tailored interventions.
Building the Oncology System of the Future
Gary Lyman, MD, MPHCo-DirectorFred Hutchison Institute for Cancer Outcomes Research
Spending on Medicines in Leading Therapy Areas
http://www.imshealth.com/portal/site/imshealth. Accessed May 2014.
Cancer Care Costs Rising Faster Than Overall Healthcare CostsC
um
ula
tive
% In
cre
as
e
Cancer Medical Cancer
Medical
Cancer DrugsCancer Drugs
HealthcareHealthcare
US GDP US GDP
Note: In 2014, 9 of 12 anticancer therapies approved estimated to cost ≥ $10/000/month.
Eight of Top Ten Most Expensive Drugs Are Cancer Drugs
Top Ten Medicare Drugs 2012 In millions
• Ranibizumab $ 1,220
• Rituximab cancer treatment $ 876
• Infliximab injection $ 704
• Injection pegfilgrastim 6 mg $ 642
• Bevacizumab injection $ 624
• Aflibercept 1 mg $ 384
• Denosumab injection $ 347
• Oxaliplatin $ 309
• Pemetrexed injection $ 292
• Bortezomib injection $ 278
Includes carrier claims only (physician office and DME). Outpatient Prospective Payment System (OPPS) claims are excluded.
Source: Moran Company Analysis of Medicare Physician/Supplier Procedure Summary File
Expenditures on Chemotherapy and Targeted Therapies
Rising Healthcare Costs
• Cost matters to payers• Cost matters to society• Cost affects access and outcomes• Out of pocket costs matter to patients & affect Rx decisions
Side
effe
cts B
enefits
Costs
Value in Cancer Care: Conceptual basis
• Health Outcome Achieved per $ Spent
• A multidimensional concept that considers returns for expenditure
“Price is what you pay; Value is what you get.” - Warren Buffett
Improving Value: Unique Challenges for Oncology
• Sense of urgency - many cancer patients have poor prognosis & facing imminent death
• Pressure to use newest technologies/ treatments• Treatments expensive, making cancer care a hardship or unaffordable• Treatments can be highly toxic/life-threatening• Providers often reluctant to switch to best supportive care, even at end
of life
2009 IOM Report: Assessing and Improving the Value in Cancer Care
National Quality and Value Initiatives
Hutchinson Institute for Cancer Outcomes Research
HICOR Research Priorities
• Cancer Care Delivery Research• Effective Translation of Policy to Clinical Practice• Supporting Evidence-Based Clinical Practice
• Value in Cancer Care• Economic Burden of Cancer for Patients and Society• Cost-effectiveness Alongside Clinical Trials• Value of Information Methods• Early Health Technology Assessment
HICOR’s Value in Cancer Care Consortium
Regional Metrics of Value in Cancer
Care
ASCO/ABIM Choosing Wisely Adherence
MetricsVALUE metrics: MEANINGFUL for the region, FEASIBLE and efficient to collect, and ACTIONABLE.
RATE OF UTILIZATION of interventions that are not recommended / UNSUPPORTED BY EVIDENCE
Metrics provide a data-driven foundation for prioritizing needs/opportunities to improve care
Consortium serves as a network for cancer care delivery research experiments
Project Implementation and Monitoring
Data collection: baseline, 6 & 12 months Tumor registry, billing, clinic & patient reported data
Pre
Post
Pre
Post
HICOR’s Value in Cancer Care Consortium
Regional Metrics of Value in Cancer
Care
ASCO/ABIM Choosing Wisely Adherence
MetricsVALUE metrics: MEANINGFUL for the region, FEASIBLE and efficient to collect, and ACTIONABLE.
RATE OF UTILIZATION of interventions that are not recommended / UNSUPPORTED BY EVIDENCE
Consortium serves as a network for cancer care delivery research experiments
Metrics provide a data-driven foundation for prioritizing needs/opportunities to improve care
Participating OrganizationsAllied Health Advocates ◊ Centers for Medicare and Medicaid, Region X ◊ Confluence Health ◊
Evergreen Health ◊ Fred Hutchinson Cancer Research Center ◊ Gilda’s Club ◊ Group Health ◊ Island Hospital ◊ Multicare Regional Cancer Center ◊ Northwest Medical Specialties ◊ Overlake Hospital ◊
Premera Blue Cross ◊ Providence Regional Cancer Partnership ◊ Seattle Cancer Care Alliance Virginia Mason Medical Center ◊ Swedish Cancer Institute ◊ Washington State Health Care Authority ◊
Washington State Medical Oncology Society
Allied Health Advocates ◊ Centers for Medicare and Medicaid, Region X ◊ Confluence Health ◊ EvergreenHealth Fred Hutchinson Cancer Research Center ◊ Gilda’s Club ◊ Island Hospital ◊ Northwest Medical Specialties
Overlake Hospital ◊ Providence Regional Cancer Partnership ◊ Washington State Health Care Authority
Value in Cancer Care Summit
Top Six
Desirability
Feasibility
