Not for redistribution. © 2014 Oncology Management Services, Consultants in Medical Oncology & Hematology Will Value-Based Payment Systems Foster Better

Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology

Will Value-Based Payment Systems Foster Better

Survivorship Care

Oncology PCMHJohn D. Sprandio, MD, FACPChief Physician,Consultants in Medical Oncology and Hematology (CMOH), PCChairman, Oncology Management Services, Inc


Meeting Survivorship Needs

• Practice transformation, care delivery models• Associated payment reforms• Are care models and payment methods re-

aligning patient and provider behavior and driving patient-centered care?

• What’s missing?• When is it coming?

1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results

Non-risk adjusted practice dataPreliminary risk-adjusted payer data

4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update

Alternate payment models Scalability of Oncology PCMH

model

Joint Principles of PCMH

Medical Neighborhood

Value in Cancer Care

Enhancing Value in Cancer Care

Oncology PCMH Quality & Value Driver DiagramOncology PCMH Quality & Value Driver Diagram

Triple AimPatient-,Payer-,and Provider-Centered

Outcomes


Outcomes

Primary Driver Care Team Environment Delivery Standards

Services


Services

Secondary Drivers Process of Care Standards,

Care Integration, Evidence Base



National Committee for Quality Assurance

PCSP Recognition PCOC standards



American College of Surgeons

Commission on Cancer Data Collection NCDB

Treatment & PC Standards



Treatment & PC Standards NCCN

Treatment Guidelines Survivorship Guidelines

NCCN Treatment Guidelines

Survivorship Guidelines

ASCO QOPI Standards Survivorship Guidelines


Institute of Medicine National Quality Forum

National Cancer Policy Forum



Patient Advocacy Data NCCS, CSC, ACS


American College of Physicians PCMH-NAmerican College of Physicians PCMH-N

Engagement & Orientation Patient Responsibilities

Practice Responsibilities Goals, Insurance Issues



Patient Navigation Multidisciplinary Input Scheduling & Tracking


Execution of Care Staging/Guideline Adherence Standardized Processes/Data

Care Coordination Communication



Symptom Management

On Demand Access/Visits Performance data collection Track success of Palliation

Symptom Management On Demand Access/Visits

Performance data collection Track success of Palliation

Survivorship Care Standardized Care Plans

Coordination Agreements



Goals of Therapy Documented PS Driven Discussions

Shared Decision Making



Data Driven ImprovementData Driven Improvement

Multi-disciplinary Guideline

Concordance


Concordance

Palliation Symptom Management Focus on Performance

Status (PS)


Status (PS)

Avoidable Resource Utilization

ER/Hospitalizations Imaging & Lab



Patient & Family Experience of Care


End of Life Care Hospice Enrollment

Place at Time of Death Resource Utilization



Survivorship Care Standardized

Primary PCMH


Primary PCMH

Total Cost Of Care Medical, Surgical, Lab

Radiation, Imaging


Radiation, Imaging ©2014 Oncology Management Services, Ltd.

Payer Based Episode and “OMH” Programs

CMS & Commercial



Outcomes


Outcomes


Services


Services





































Symptom Management














Concordance


Concordance


Status (PS)


Status (PS)












Primary PCMH


Primary PCMH


Radiation, Imaging


Radiation, Imaging


CMS & Commercial

©2014 Oncology Management Services, Ltd.



Outcomes


Outcomes


Services


Services





































Symptom Management














Concordance


Concordance


Status (PS)


Status (PS)












Primary PCMH


Primary PCMH


Radiation, Imaging


Radiation, Imaging


CMS & Commercial




Outcomes


Outcomes


Services


Services





































Symptom Management














Concordance


Concordance


Status (PS)


Status (PS)












Primary PCMH


Primary PCMH


Radiation, Imaging


Radiation, Imaging


CMS & Commercial



How We Equipped Our Practice for the Oncology Patient-Centered Medical Home®





model


Go to nearest ER2.15%

Chemo Suite Intervention0.21%

Office visit today3.93%

Office visit tomorrow3.60%

Referred to Pri-mary/

Special-ist

5.30%

Pt sent for Ra-

dio-graphic Study2.01%

Manage Symptom(s) at home82.80%

Outcome of Clinical Nurse Triage Phone Calls in 2014n = 4832 clinical phone calls

7.53% of patients were seen in the of-fice within 24 hours of call


2.600 2.567

2.067

1.604

1.2731.119

0.9100.818

0.7030.550 0.541

0.000

0.500

1.000

1.500

2.000

2.500

3.000

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Year

Average emergency room (ER) Evaluations per chemotherapy patient per year (APCPPY)

for the CMOH patient population , 2004-2014.

ER

Eva

lua

tio

ns p

er

ch

em

oth

era

py p

ati

en

t p

er

USON/Milliman: Approximately 2 emergency room visits per chemotherapy patient per year

(14 million commercially insured; 104,473 cancer patients)Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009

© 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology

2007 2008 2009 2010 2011 2012 2013 20140.000

0.200

0.400

0.600

0.800

1.000

1.200

1.0801.055

0.876

0.605

0.528

0.694

0.562

0.499

Average Admissions per Chemotherapy Patient Per Year (APCPPY) for CMOH patient population, 2007-2014

APCP

PY

USON/Milliman: Approximately 1 hospital admission per chemotherapy patient per year (n=14 million commercially insured; 104,473 cancer patients)Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009

Measure Line(s) of Business

Hospitalizations per chemotherapy treatment (within 60 days) Commercial and Medicare Advantage

ER Visits per chemotherapy treatment (within 60 days) Commercial and Medicare Advantage

Hospice days in last 60 days of life per chemotherapy patient Medicare Advantage Only

Hospitalizations in last 30 days of life per chemotherapy patient Medicare Advantage Only

Chemotherapy treatment in last 30 days of life per chemotherapy patient Medicare Advantage Only

Payer Risk-Adjusted Oncology PCMH Measures

Initial 7 months of contract (risk adjusted)Commercial Medicare Advantage

CMOH Rate 0.024 0.025

Plan Benchmark (Market basket based on CMOH’s Top 15 Dx codes)

0.036 0.067

Admissions Saved per chemotherapy treatment 0.012 0.041

CMOH % Reduction in Admissions vs Network 33% 61%

Average Cost per Admission $ $

Total Savings $ $

xx% Shared Savings $ $

Hospitalizations per chemotherapy treatment (within 60 days)

Initial 7 months of contractMedicare Advantage

CMOH Rate 0.000

Plan Benchmark 0.447

Admissions Saved per patient 0.447

Total admissions saved xx.x(0.447 x xx expired pts)

Average Cost per Admission $

Total Savings $

xx% Shared Savings $

Hospitalizations in last 30 days of life per chemotherapy patient

Chemotherapy treatments in last 30 days of life per patient

Initial 7 months of contractMedicare Advantage

CMOH Rate 0.000

Plan Benchmark 0.458

Chemotherapy treatments saved/patient 0.458

Total chemotherapy treatments saved xx.x(0.458 x expired patients)

Average Cost of chemotherapy treatment $

Total Savings $

xx% Shared Savings $

Hospice days in Last 60 days of life (Medicare Advantage only)Initial 7 months of contract

15.25 •CMOH

13.84 •Plan Benchmark

Yes •10% Better than Plan





model

Provider Ability and Accountability Payment Reform for Cancer Care

30% of traditional Medicare tied to PCMH, ACO, Budgeted Payments by 2016 – 50% by 2018 90% of traditional Medicare will contain Quality & Value parameters by end of 2018


Payment Reform

UnitedHealthcare: Lee Newcomer, Episode and Bundled programsPCORI funded Oncology PCMH Project (SEPA)

NCQA, OMS, ASCO, RAND, NCCS, IBCCOME HOME PROJECT: OMH, CMMI, IOBS Horizon Blue Cross, RCCA: Medical Oncology BundlesOncology Bundled Payment Consortium - OCM

CAP, CMS, CMMI, multiple payersCMS Oncology Payment Reform TEP - OCM

MITRE, Brookings, RAND, CMS, CMMIASCO and COA Payment Reform InitiativesOMS Alternate Payment Methods (Pennsylvania)

IBC, Keystone First, Capital Blue Cross


CMS Oncology Care Model (OCM)

Combined features of CMS Oncology Payment Reform TEP + CAP Bundled Payment Consortium

Medical oncology treatment episodes - broadly applied PCMH Practice Transformation

• Patient Navigators• Enhanced Coordination• Structured Care Management Plan (IOM)• 24/7 access to clinician with records• Adherence to nationally recognized treatment guidelines• Oncology specific EHR, stage 2 MU by end of year three• Data driven quality improvement program


CMS Oncology Care Model (OCM)

Performance Metrics – reported quarterlyDriven by Care Team execution of PCMH processes

• ER visits/Hospital admissions (episode + 6 months & EOL)• CAHPS (oncology version)• Comprehensive health assessment, including PS • Psychological screening (once/episode)• Palliative care (concurrently or via formal consultation)• Transition coordination and follow-up testing/OP visits• Medication reconciliation • Pain management• Hospice Utilization• Resource Utilization (drugs, radiation therapy, imaging, laboratory)• Results of data driven quality improvement efforts


Standardization of Oncology PCMH Processes

• Standardized Engagement & Orientation• Patient Navigation

• Shared Decision-MakingExplanation – specific TNM & molecular stagingPrediction – natural history, impact on performance status Treatment options – consensus based guidelinesFinancial counseling – patient OOP expensesPatient Preferences – life goals, family responsibilities, hobbies Plan of Care – discussed and mutually agreed uponGoals of therapy defined, modified – curative or palliative Written or electronic plan shared with patient/stakeholders

• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy



• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management

• Survivorship Care • Treatment team is the survivorship care team• “Care Management Plan” transitions to “Survivorship Care Plan”• Care plan templates for site and stage (ASCO)• Treatment and clinical summary (toxicities and co-morbidities)• Genetic history, updating family history • Documentation and management of residual symptoms• Surveillance, screening, risk reduction, health promotion• Community resource utilization • Coordination agreements with primary care team (ACP PCMH-N)

Responsibility matrix defined – primary, medical, radiation and surgical oncology • Goals of therapy





model


Oncology Management Services (OMS)

• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA

• IRISTM App development• IRIS: integrates processes, work-flow, data collection, data

presentation, response to data, documentation, communication and performance feedback to providers

• Aggregates, analyzes, re-organizes clinical and performance data in a consumable way that fits the work-flow of cancer care

• 90% of data collected and presented prior to physician entering the exam room – focus: shared complex decision-making

• Middleware, FHIR enabled, EMR agnostic app development• Scalability of an Oncology PCMH Model


Oncology Management Services (OMS)• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA• IRISTM Development

• Scalability of an Oncology PCMH ModelPayment reform and technology

• Payer and provider collaboration• Technology - not just about data – it is a human endeavor

Integration of “big data” of obvious importance “Small data” involved in shared decision-making is equally important

• Technology supporting the patient-physician interactionIs a template for practice transformationDefines care-team roles, efficient work flow, fixes accountabilityEnhances flow of information in complex careCentral to reduction in unnecessary resource utilization

Thank youContact Information

John D. [email protected]

Visit us at www.opcmh.com to register for OMS’ Healthcare Delivery Seminar

mailto:[email protected]


• Appendix



Consistent approach by the care team• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy



• Patient Engagement & Orientation• Define role of nurse and patient navigators, physicians, etc• Modes of enhanced access & coordination defined• Financial counseling – details of insurance coverage • Patient reporting & practice responsibilities• Practice as “Point of First Triage” • Symptom and disease management strategies (nurse triage)• Patient Portal education

• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy



• Patient Engagement & Orientation

• Patient Navigation• Lay Navigators• Scheduling of all imaging, laboratory testing • Precertification of necessary imaging• Scheduling all external provider appointments

Oncologic and non-oncologic

• Tracking test results and consultation reports to completion Re-scheduling when necessary

• Interface/scanning of reports • Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy



• Standardized Engagement & Orientation• Patient Navigation

• Shared Decision-MakingExplanation – specific TNM & molecular stagingPrediction – natural history, impact on performance status Treatment options – consensus based guidelinesFinancial counseling – patient OOP expensesPatient Preferences – life goals, family responsibilities, hobbies Plan of Care – discussed and mutually agreed uponGoals of therapy defined – curative or palliative Written or electronic plan shared with patient/stakeholders

• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy



• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making

• Execution of CareStandardized outpatient processes and work flowPatient self assessment questionnaire (PSAQ)Data collection and presentation drives decisionsAdherence to multidisciplinary and chemotherapy guidelinesNavigation, communication & coordination of all aspects of careProvider team accessibilityPerformance metrics monitored

• Care coordination • Symptom Management• Survivorship Care• Goals of therapy



• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care

• Care coordinationMultidisciplinary input – Primary, Surgery, Radiation, Medical OncologyTimeline of intervention discussed and scheduledStandardized communication among primary care & oncology teamsCoordination of care between oncologist, primary and other specialistsCoordination of care arrangements define responsibilities (PCMH-N)Transitions of care OP to ER or Admission, admission to OP

• Symptom Management• Survivorship Care• Goals of therapy



• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination

• Symptom management – during and between OP visitsStandardized symptom data collection, grading & documentationAuto-populated fields in documentation driving physician

response Longitudinal view of success of symptom managementDocumentation of specific recommendations shared with patientTelephone triage 24/7 - standardized algorithms Documentation of type and disposition of every call

• Survivorship Care• Goals of therapy



• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management

• Survivorship Care • Treatment team is the survivorship care team• “Care Management Plan” transitions to “Survivorship Care Plan”• Care plan templates for site and stage (ASCO)• Treatment and clinical summary (toxicities and co-morbidities)• Genetic history, updating family history • Documentation and management of residual symptoms• Surveillance activity and screening• Community resource utilization • Coordination agreements with primary care team (ACP PCMH-N)

Responsibility matrix defined – primary, medical, radiation and surgical oncology • Goals of therapy



• Standardized Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care

• Goals of therapyPerformance Status driven decision making in non-curative setting

Standardized PS measurementDocumentation of ongoing goals dialogue based on PS changes

Goals of therapy updated via replay of: Explanation, Prediction, Options, Patient Preference, Plan of

Care Hospice utilization monitored

Chemotherapy Guidelines

Oncology PCMHConcurrent Delivery of Palliative Care

Oncology PCMHEnd-of-Life Care

Oncology PCMHSurvivorship Care

Oncology PCMHTransitions of Care Responsibility





model

Quality and Cost Are Completely Intertwined





model

Projected % Reduction in Total Cancer Care Cost

1-3 Chemotherapy pathways program4-6.3 Inpatient hospitalizations (5-25% reduction)0.6-1.1 ER evaluations (20-40%)0.1-.4 Diagnostics0.9-1.9 End-of-life care coordination

Total 6.6 – 12.7 % reductionAnnual cancer “spend” $125B = $8-16B savings

Adapted from international consultants assessment of OPCMH® cancer care model

OPCMH® Impact on Practice





model

















Oncology PCMH program transformation services• Local Contracting• NCQA Collaboration• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capitol Blue Cross Project• Regional Value-Based Oncology IPA• IRIS Development• Scalability of an Oncology PCMH Model



• Local Contracting• Two active Alternative Payment Arrangements (CMOH)

(1) 4.5 years durationEnhanced E&M, infusion service payments relative to all

patients(2) 15 months duration

Shared savings relative to all actively treated patients – ER visits, Admissions, and EOL related ER, admissions, hospice utilization

Both contracts benchmarked against the market(3) Failed contractual experiment (5% of 12% of CMOH patients)

• NCQA Collaboration• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model



• Local Contracting

• NCQA Collaboration • Patient Centered Specialty Practice (PCSP) standards

Extraction of Primary Care elements and featuresPrioritization of standards, features and elements for specialty care

• Draft development of Patient Centered Oncology Care (PCOC) Standards – refined in PCORI project in SEPA

• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model



• Local Contracting• NCQA Collaboration

• CMS TEP & Bundled Payment Consortium (OCM)• CMS technical expert panel contribution

PCMH capabilities central to practice eligibility requirementsCMS Oncology Care Model 2016

• CAP Oncology Bundled Payment ConsortiumEpisode based payment model around Medical Oncology ServicesConsortium influenced OCM modelUHC MD Anderson Head & Neck Program (true bundle)

• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model



• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)

• PCORI Project, Southeastern PA• NCQA led, PCORI funded oncology PCMH project

NCQA, ASCO, OMS, RAND, IBC, Aetna, NCCSFive practices ranging from 4 to 44 physicians, 4 different EMRsPCOC standard under development (PCSP backbone)Reporting: Transformation, utilization and patient satisfactionProvider incentive: participation in Alternate Payment Arrangements

• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model



• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA

• Capital Blue Cross Project (East Central PA)• Payer sponsored transformation support• Payment reform aligned with CMS OCM

Enhancement of E&M for all patients based on OMS confirmed practice PCMH capabilities and milestonesShared savings arrangement included Benchmark – the CBC network

• Five community based practices beginning 6/30/15• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model



• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)

• Regional Value-Based Oncology IPA• Emergence of a large independent Primary Care Network

Seeking Value-Based specialty providers

• Active discussions with referral base, providers and payers• IRISTM Development• Scalability of an Oncology PCMH Model















Documents

Not for redistribution. © 2014 Oncology Management Services, Consultants in Medical Oncology & Hematology Will Value-Based Payment Systems Foster Better