oncology management: the aetna experience in personalized

Atlantic Information Services, Inc.1100 17th Street, NW, Suite 300 • Washington, DC 20036 • 202-775-9008 • www.AISHealth.com

Oncology Management: The Aetna Experience in

Personalized, Value-Based Care

To register additional people for the Webinar; to obtain the phone number, password/PIN number or other logistics for the meeting; or to purchase a recording of the Webinar, call AIS at 800-521-4323.

Ira M. Klein, MD, MBA, FACP National Medical Director in the Office of the Chief Medical Officer

Aetna Inc.

Michael Kolodziej, MD National Medical Director, Oncology Solutions, Office of the Chief Medical Officer

Aetna Inc.

Wednesday, April 9, 20141:00 – 2:30 Eastern time12:00 – 1:30 Central time11:00 – 12:30 Mountain time10:00 – 11:30 Pacific time

C4P15

About the Speakers

IRA M. KLEIN, MD, MBA, FACP, is a National Medical Director in the Office of the Chief Medical Officer for Aetna Inc., holding the position of Clinical Thought Leadership and responsible for core program development across the enterprise. He recently transitioned from his previous role of almost two years as Chief of Staff to the Chief Medical Officer at Aetna, having been in this role since 2011, and remains as part of the team responsible for communicating and deploying the strategic efforts of the CMO in multiple areas, including leveraging of business acquisitions, and clinical integration and clinical program development. He joined Aetna in 2006 as a Medical Director in the Northeast Region and transitioned to the corporate-level National Accounts Sales and Support group in 2009 where he was involved in the development of new benefits designs, financial and clinical analytics for National Accounts and the evolution of oncology strategies. Prior to joining Aetna, Dr. Klein was the Medical Director for Quality and Case Management at Bayshore Community Health Services in New Jersey. Before that, he also served as the Chief Medical Officer of Elderplan, an 11,000-member Medicare Social HMO that focused on the frail elderly. Dr. Klein received his B.S. in Pharmacy and an M.B.A. from Rutgers University, and his medical degree from the University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School. He completed his residency in internal medicine at Brown University and Robert Wood Johnson University Hospital. Contact Dr. Klein at [email protected].

MICHAEL KOLODZIEJ, MD, is the National Medical Director, Oncology Solutions, Office of the Chief Medical Officer for Aetna Inc. He leads the strategic development, design and implementation of Aetna’s cancer care programs. Dr. Kolodziej attended college and medical school at Washington University in St. Louis where he was Phi Beta Kappa and Alpha Omega Alpha. He completed internal medicine and hematology-oncology training at the University of Pennsylvania in Philadelphia. After completing training, Dr. Kolodziej joined the faculty at the University of Oklahoma School of Medicine where he was an associate professor. He joined New York Oncology in the winter of 1998 and was a partner in the practice until December 2012. He was an active member of the US Oncology Pharmacy and Therapeutics committee, on the executive committee from 2002-2011 and chairman from 2004-2011. He served as Medical Director for Oncology Services for US Oncology from 2007-2011. In this role, he helped direct the implementation of the USON clinical pathways initiative, the integration of the USON EMR into this program, and the development of the USON disease management and advanced care planning programs, now known as Innovent Oncology. He has published several manuscripts and given several presentations on cost of cancer care, oncology reimbursement reform, and use of evidence based treatment to enhance value. He is a Fellow of the American College of Physicians and is a member of the board of the Personalized Medicine Coalition. Contact Dr. Kolodziej at [email protected].

Moderator: Angela Maas, managing editor of AIS’s Specialty Pharmacy News and Drug Benefit News

Three Ways to Submit Your Questions for the 30-Minute Q&A Session

Speakers’ presentation should run approximately 60 minutes, with 30 minutes of questions and answers. Questions may be submitted in three different ways:

Prior to the Webinar

(1) Email your question(s) to moderator Angela Maas at [email protected] or

During the Webinar

(2) To send a question from the Webinar page, go to the Chat Pod located in the lower left corner of your screen. Type your question into the dialog box at the bottom and then click on the blue send button or

(3) Dial *1 on your phone keypad and an operator will connect you to the moderator so that you can ask your question(s) “live” with the Webinar participants listening

2

About the Sponsor — Atlantic Information Services, Inc.Atlantic Information Services, Inc., (AIS) is a publishing and information company that has been serving the health care industry for more than 25 years. It develops highly targeted news, data and strategic information for managers of health plans, hospitals, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, looseleafs and Web services, books, strategic reports, databases, Webinars and management seminars.

AIS publishes several highly practical publications that cover oncology management, including:

• SPECIALTY PHARMACY NEWS is a monthly newsletter packed with 12 pages of business news and management strategies for containing costs and improving outcomes related to high-cost specialty products. Designed for health plans, PBMs, providers and employers, the hard-hitting newsletter contains valuable insights into benefit design tactics, specialty markets for certain conditions, formulary decisions, merger and acquisition activity, payer-provider partnerships, patient adherence strategies, and new products.

• DRUG BENEFIT NEWS is a hard-hitting newsletter for health plans, PBMs, pharma companies and employers. Published biweekly, it delivers both timely news stories and in-depth accounts of cost management strategies that are being employed by drug purchasers. Coverage includes up-to-the minute news of industry consolidation, strategies for participation in exchanges, generic promotion tactics, formulary decisions, innovative benefit designs, drug pricing methodologies, PBM contracting, changes in Part D and other federal initiatives, and much more.

• HEALTH PLAN WEEK is the nation’s #1 source of timely, objective business, financial and regulatory news of the health insurance industry. Published since 1991, the 8-page weekly features valuable insights and strategies for health plan managers and others who must monitor the activities and performance of health insurers. Coverage includes new benefit designs and underwriting practices, new products and marketing strategies, mergers and alliances, financial performance and results, Medicare and Medicaid opportunities, disease management, and the flood of reform-driven regulatory initiatives including medical loss ratios, exchanges, ACOs and myriad benefit design changes that are mandated.

Learn more about all of AIS’s products and services at the Marketplace at www.AISHealth.com

This publication is designed to provide accurate, comprehensive and authoritative information on the subject matter covered. However, the opinions contained in this publication are those solely of the speakers and not the publisher. The publisher does not warrant that information contained herein is complete or accurate. The conference materials are published with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.

Copyright © 2014 by Atlantic Information Services, Inc. All rights reserved.

Organizations participating in the April 9, 2014, Webinar are hereby permitted to make one photocopy of these materials for each of their employees or contractors who listen to the live broadcast of the Webinar.

3

Webinar Program• Introductions/Administrative Reminders

• Speakers’ Presentation

• 30-Minute Q&A Session

Webinar materialsPayer Considerations in Oncology ......................................................................................................page 5

Presentation by Ira M. Klein, MD, MBA, FACP, and Michael Kolodziej, MD

Selected Specialty Pharmacy News Articles ....................................................................................page 84

Webinar outlinePart 1: Ira M. Klein, MD, MBA, FACP, Aetna Inc., and Michael Kolodziej, MD, Aetna Inc.

• Cancer is a significant healthcare challenge both in cost and delivery of quality care

• Principles of Aetna’s strategy to manage all the forces at play

• Adherence to evidence-based guidelines

• Oncology patient-centered medical homes

• Different payment reform options in contracting

• Enabling providers

• Principles of a coordinated care management oncology program

• The “5 step” oncology care delivery process

• Assessing genomic assays for accuracy and clinical relevance

• End-of-life care

Part 2: Questions and Answers

4

©2012 Aetna Inc. A differentiated strategy for cancer care

Quality health plans & benefits Healthier living Financial well-being Intelligent solutions

Michael Kolodziej, MD, FACP

National Medical Director, Oncology Solutions

Ira Klein, MD, MBA

National Medical Director, Clinical Thought Leadership

April 9, 2014 – AIS webinar

Payer Considerations in Oncology

5


Our values guide our approach to creating a better health care system

To make quality health care more affordable and more accessible

Our cause

Our strategy To be the global leader in empowering people to live healthier lives

6


Cancer is the most costly medical item and increasing at 2-3x the rate of other costs

1996 2010 0%

1000% $55 B

$123 B

Cumulative percentage increase

*2010 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC www.cancer.gov/newscenter/pressreleases/2011/CostCancer2020

Cancer care is the leading

edge of medical cost

trend

Annual

Increase

Cancer Drugs 20%

Cancer Medical 12-18%

Health Care 9%

US GDP 3%

Medical Rx 30.8% $1.5B

Inpatient 23.3% $1.1B

Radiology 22.4% $1.1B

Specialist Physician 9.4% $483M

Aetna's top

cost drivers

in cancer care

7

http://www.cancer.gov/newscenter/pressreleases/2011/CostCancer2020


Health Care Premiums are Growing at 3x the Rate of Inflation and Wages

Cumulative increases from 1999-2012

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012.

Bureau of Labor Statistics, Consumer Price Index and Employment Statistics Survey

172% Health insurance

premiums

38% Overall inflation

47% Workers’ earnings

8


48% (contributions + out of pocket) 52%

2007 - 2012P COST INCREASE

$6,228 $2,989 $3,239

COST SHARE

Consumers are Paying for Half the Increase in Medical Premiums

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012. Bureau of Labor Statistics, Consumer Price Index and Employment Statistics Survey

Consumer Employer

9


The Health Care System Produces $750 Billion in Yearly Waste

Source: Institute of Medicine; 2009 data

~30% of health spending is waste

Fraud Unnecessary

services

Inefficient

care delivery Excess administrative

costs

Inflated

prices

Prevention failures

U.S. health care

system waste

27%

7% 10%

14%

17% 25%

10


Life

exp

ect

ancy

(yea

rs)

$2,000 $4,000 $6,000 $8,000 0 74

76

78

80

82

Health care spending (PPP US$)

USA

Hungary

Estonia Mexico

Poland

Czech Republic

Chile Slovenia

Korea

Israel

New Zealand

Denmark

Norway

Switzerland

France

Germany

Belgium

U.K.

Spain

Despite the excess spending, our health status trails less developed nations

11


From Jemal, A. et al. Death Rates for Cancer and Heart Disease for Ages Younger than 85 Years and 85 Years and Older, 1975-2005 CA Cancer J Clin 2009;59:225-249.

Death rates from cancer are decreasing but the decline is small compared to heart disease.

12


• Cancer treatment is $137B in medical spend and growing 1

• Bulk of costs driven by care delivered during diagnosis and end-of-life phases2

• Despite community care being more effective at lower cost, community practice economics are unsustainable due to changes in reimbursement and rising administrative costs3

• New economic models, like medical homes, can enable sustainable community care yet oncologists lack the knowledge and finances to transform 3

1. NCI Cancer Prevalence and Cost of Care Projections 2012, represents medical costs only 2. MedStat Cancer Cost Data 2012 3.Journal of Oncology Practice, “Improving Wait Time for Chemotherapy in an Outpatient Clinic” January 2012 3. Interviews with community Oncologists (September 2012)

Cancer is a significant healthcare challenge both in cost and delivery of quality care

Expensive and Challenging

Cancer care is expensive Optimizing care delivery is challenging

13


Responses to the huge and growing expense of cancer care?

• Pay less • Manage more (prior auth) • Shift responsibility to member (co-pay, value

based insurance, reference pricing) • Pay for performance (gain share) • Shift risk (ACO)

14


Assessing the Cost and Efficacy in Cancer Care means solving for the Value Equation

V =

Q

C

• Guideline Based Therapies

• Targeted Impact • Low Toxicities • Improved Survival • Improved QOL

• Best Supportive Care • Avoidance Hospital Days • Avoidance ED Visits • Site of Service Costs ↓ • Medically Unnecessary

Care ↓ at EOL

15


• Drive efficient use of evidence-based medicine – Build a platform that provides content and workflows – Integrate into the Aetna and provider systems – Simplify the administrative processes for providers – Improve the care experience for the members with cancer

• Avoid waste and misuse of medical services – Better provider alignment, which includes transparency & reporting

(e.g., Oncology Patient Centered Medical Home) – Better network (narrow, tiered) – Better decision support strategies – Better patient support in active treatment and care transitions

• Leverage and integrate the many current (and future) medical and pharmacy cancer-care initiatives

– Seamless, end to end cancer experience for Aetna members and providers

The principles of our strategy are simple

16


It’s a “win-win” strategy to manage all the forces at play

17


The right alignment of stakeholders drives the best possible patient outcomes

PLAN SPONSOR – PROVIDER Incentives based on quality

Decision support technology

NATIONAL NETWORK ACCESS PROVIDER - PAYER Plan design steerage to quality

and efficiency

18


Study: “Cost Effectiveness of Evidence-Based

Treatment Guidelines for the Treatment of

Non–Small-Cell Lung Cancer in the Community Setting”

Published: Journal of Oncology Practice (ASCO

Peer Reviewed Journal), 1/19/2010

Increased adherence to evidence based guidelines lowers cost without negatively impacting treatment efficacy

No change in overall survival between the study groups

Source: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting”. Journal of Oncology Practice. January 2010. Volume 6. No.1. p 12-18

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

Purpose: Evaluate the cost effectiveness of

evidence-based treatment pathways for NSCLC patients

Conclusion: Results of this study suggest that treating

patients according to evidence-based guidelines is a

cost-effective strategy for delivering care to those with NSCLC.

Overall survival by Pathway status.

19


Enabling physicians with clinical decision support helps them better care for patients and reduce costs

22


Clinical Decision Support Options

23


We’re building a national network of Pay for Value supported oncology practices Expect 10-20 more oncology PCMH’s to come on-line by end of 2014

Oncology PCMH’s

CDS P4V as of 3/1/14

CDS P4V as of 9/1/14

CDS P4V in discussion

CDS = Clinical Decision Support P4V = Pay for Value programs

24


40

50

60

70

80

90

100

110

120

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

Ge

ne

ric/

Pat

en

t Ex

pir

atio

n

2005 Duragesic Transdermal Sandostatin

2006 Zofran

2007 Kytril Gemzar

2008 Femara Camptosar Fosamax

2011 Etopophos Xeloda Aromasin Femara Anzemet Istodax Plavix Avonex Neumega

2012 Eloxatin Enbrel Vidaza

2013 Neupogen Zometa Xeloda Taxotere Temodar Dacogen Epogen Procrit Remicade

2014 Remicade Leukine Rapamune Evista Xeloda

2015 Epogen Aranesp Rituxan Epogen Procrit Gleevec Aloxi Neulasta Peg-Intron Emend oral Alimta

2017 Neulasta Sandostatin Velcade Tysabri Iressa Velcade Xolair

2018 Tarceva Avastin Herceptin Clolar

2019 Revlimid Zytiga Exjade Boniva Orencia

2020 Nexavar Tykerb Revlimid Vectibix Sprycel

2021 Sutent Soliris

2023 Thalomid

Generic Introduced Patent Expiration

2016 Enbrel Erbitux Zevalin Elitek Humira Prialt

By 2020, there will be

a robust portfolio of

generic and biosimilar

options.

Estimated Dates of Possible First-time Generics/ RX-to-OTC Market Entry (June, 2012) http://www.medcohealth.com/art/corporate/anticipatedfirsttime_generics.pdf

26


Keeping score

Minimal standards

Training

Relationship

Pathways are an important first step

27

http://public.ifbyphone.com/blog/voice-based-marketing-automation-impress-bell/


http://www.collegenetwork.com/blog/lean-six-sigma-online


• Personal physician

o Each patient has an ongoing relationship with a personal physician o Personal physician leads a team of individuals that takes responsibility for the

ongoing care of patients o Personal physician is responsible for providing for all the patient’s health care

needs or arranging care with other qualified professionals

• Care is coordinated across health care system

• Quality and safety are hallmarks of the medical home

• Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication

• Payment recognizes the added value provided to patients who have a patient-centered medical home

What are the PCMH joint principles?

30


• Improved health outcomes supported by doctors’ use of clinical decision-support tools to improve care management, tracking and adherence to evidence-based guidelines

• Reduced hospitalizations and ambulatory care

o Includes primary and readmissions

o Includes sensitive specialty/facility and other costs

• Improved transition of care

• Shared decision-making

• Increased engagement in preventive health and wellness

Expected benefits to health care consumers

31


Impact of a cancer management program: An Innovent/Aetna pilot

Study Design • Prospective, non-randomized evaluation of patients enrolled in the Innovent

Oncology Program

Location • Patients seen by Texas Oncology physicians

Study period • Innovent Oncology Program 6/1/2010-5/31/2012; Program yr 1: 6/1/2010-

5/31/2011; Program yr 2: 5/1/2011-4/31/2012

Inclusion

• Aetna eligible pts diagnosed with an Innovent diagnosis initiating chemotherapy during program year 1 or year 2

• Drug costs • ER and in-patient admissions and costs

Exclusion • Patient eligible for the program in the last month of each program year • Patients with a chemotherapy claim in the month prior to the program year • Patients without a chemotherapy claim within each program year

*ASCO Quality, 2012 32


Effective patient management programs streamline care delivery and reduce costs

0%

5%

10%

15%

20%

25%

30%

ER visits In-patientadmissions

Patientsenrolled inInnoventprogram

Controlgroup

0

0.5

1

1.5

2

2.5

Controlgroup

Innovent

Avg. in-patienthospitaldays

10%

14%

18%

24%

2.1

1.2

Fewer cancer related ER visits and in-patient admissions

Fewer cancer-related in-patient hospital days

0%

20%

40%

60%

80%

Patientsenrolled inInnoventprogram

Controlgroup

On-pathways

Greater adherence to Pathways regimen

76%

63%

Opening the Black Box: The Impact of an Oncology Management Program Consisting of Level I Pathways and an Outbound Nurse Call System, 2014, American Society of Clinical Oncology

33


OPCMH™ pilot in SE Pennsylvania

• Community Medical Oncology Hematology (CMOH), founded by Dr. John Sprandio, is currently the only NCQA certified specialty medical home for oncology

• Dr. Sprandio made the decision to reengineer processes of care at CMOH in 2005, placing the patient at the center of care:

o Invested in IT infrastructure, beyond an EMR

o Minimized clinically irrelevant activity

o Fixed accountability at the physician-patient locus

o Drastically increased communication, coordination access, and engagement

• As a result, value has increased at CMOH since 2005, demonstrated through both cost reductions and quality improvement (per CMOH, to be validated in this pilot)

• One other practice in the study group, Abington Hematology Oncology, will be trained by CMOH staff throughout the pilot

34


ER visits per chemotherapy patient have dropped by 70 percent since 2005

Source: Dr. John Sprandio. Reused with permission. Do not distribute.

35


Hospital admits per chemotherapy patient have dropped by 50 percent since 2007

Source: Dr. John Sprandio. Reused with permission. Do not distribute.

36


Accreditation of OPCMH

37


FFS payments to physicians

Total physician payment

All other payments

Current Model Proposed Model

Current Model

Proposed Model

Tota

l Co

st o

f C

ance

r C

are

Tota

l p

hys

icia

n

pay

me

nt

All

oth

er

can

cer

care

sp

en

din

g e

lem

en

ts

Total

ph

ysician

paym

en

t

All o

the

r C

ance

r care

Spe

nd

ing e

lem

en

ts

FFS payments to physicians

Care coordination fee Case management payment

Payment for all other cancer care Payment for all other

cancer care

Waste and inefficiency Waste and inefficiency

Total Costs and Payments for Cancer Care To

tal P

aym

en

ts f

or

C

ance

r C

are

The Brookings Institution, Washington, D.C.

38


Different markets will support different payment reform options in contracting, and at different times:

Bundling/ Aggregation Across Providers

Case-Based Physician Payment

Traditional FFS

Value-based Pathways

Chemotherapy Management Fee

Patient-Centered OPCMH

Episode Payment for Physician

Services (Oncology, Radiology, Surgery)

Episode Payment for Physician and Hospital Services

Comprehensive Capitated Payment

Brookings Institute, November 2013

39


1. Care occurs in discrete episodes

2. There is variability that does not impact quality

3. Bundling in the form of “episode payments” has worked for other medical conditions

Why does bundling make sense in oncology?

40


Episode fee plasticity based on clinical performance

Basic Episode Fee

Reduced Episode Fee

Enhanced Episode Fee

Determinants of modifier:

ER visits, Hospitalizations, Generic prescribing, Hospice Enrollment

41


Challenges

1. Appetite and aptitude

2. Hospitals

3. Technology

4. End of life care

43


1. Average number of physicians = 4

2. About 50% utilizing an EMR

3. Staffing margins very lean

4. Unable to develop and implement standardized scripting organically.

5. Unable to measure and report impact of program.

The typical oncology practice is poorly positioned to provide enhanced clinical programs

44


We have the capabilities to equip oncologists with the tools to transition to a medical home

Care Management Support

Financial Alignment

Oncology Medical Home Solution

Information Technology

Value based contracting and benefit steerage to drive adoption

Clinical decision support tools to optimize care plan

Automated prior-authorization to reduce administrative burden

IT platform for care transitions and holistic view of patients

Optimal Staffing Model to provide leverage and coordinate care

Oncology-tailored patient applications to support patients

Pro

vid

er

Too

ls

Pat

ien

t To

ols

H

IT P

latf

orm

46


Ultimately, we are enabling providers to focus on the right outcomes for better patient results

• Adherence to NCCN guidelines/pathways

• Chemo-related hospital admissions

• Chemo-related ER visits • Cancer patients with clinical

or pathologic staging prior to 1st course of treatment.

• Chemotherapy patients with performance status on the day of treatment

• Received self-management resources/materials

• Stage IV patients with end-of-life care discussions

• Patients introduced to Advance Care Planning and facilitation

• Clinical decision support technology

• Standardized reporting for continuous quality improvement at the office level

• Oncology PCMH toolkit • Tight linkages to Aetna’s

oncology care management program

• Additional revenue opportunities through pay-for-value contracting and oncology PCMH arrangements

MEASUREABLE METRICS TECHNOLOGY ENABLED RELEVANT OUTCOMES

• Reduced avoidable hospitalizations and total bed days

• Reduced avoidable ED visits • Improved usage of evidence

based medicine with documented compliance

• Efficient drug regimen usage • Enhanced

communication/patient education

• Coordination and easy patient access to care for same day visits

• Enhanced patient understanding of therapeutic intent of therapy and life planning capabilities

47


The Oncology Nurse Navigator

1. Concept developed by Harold Freeman

2. An approach to disparities of care related to lower socioeconomic status

3. Goal of improved outcome delivered by improved ability to “navigate” the health care system

48

http://blog.cleveland.com/health/2008/12/navigators_help_cancer_patient.html


1. Based either in hospitals or large practices

2. Not focused on patients from lower socio-economic groups

3. Scripting poorly defined

4. Engagement and patient satisfaction high

5. Meaningful outcomes largely unmeasured

6. Conflict of interest issues?

How has the oncology nurse navigator role evolved?

49


What Patients need from a coordinated Care Management Oncology Program:

A Virtual Patient Navigator

50

http://www.patientnavigatortraining.org/course1/module3/characteristics.htm


1. Enhanced patient engagement executed by carefully scripted care management interventions linked to transitions of care.

2. Content focused on patient education to reduce toxicity and optimize outcome; a thorough needs assessment with identification of barriers to care and enhanced support; and improved coordination of care.

3. Case finding linked to prior authorization of expensive injected oncolytics or traditional case management triggers.

4. Sophisticated reporting using validated tools

5. Provider notification and communication

6. Builds upon existing expertise in Aetna case management

Program principles

51


We identify members at the most critical point in their cancer treatment to best support them throughout their cancer journey

DIAGNOSIS

TREATMENT PLANNING

CHEMO/SURGERY

POST TREATMENT CARE

NURSE OUTREACH

NURSE OUTREACH

Traditional regional case management model • Administration of Primary/

secondary neoplasm • Outpatient radiology/ chemo • Oncology Rx (specialty RX)

• In-patient oncology claim

More cancer patients captured earlier for better health and financial outcomes

Oncology management through ITC/

custom care unit

52


Split Fill: An enhanced oral oncolytic management program

53


Program Principles 1. Enhanced patient engagement executed by carefully scripted care management

interventions linked to dispensing. 2. Content focused on patient education and side effect management 3. Case finding linked to prior authorization of expensive, toxic oral oncolytics 4. 14-day dispensing to allow real time management of dose modifications/delays in

therapy/changes in therapy to minimize waste 5. Sophisticated reporting using validated tools 6. Provider notification and communication

Why Split Fill?

54


How Split Fill Will Work

1. Patient identification and initial outreach with focus on education. 2. Ongoing evaluation of symptom and toxicity burden. 3. Just in time delivery of effective, well tolerated therapy 4. Avoidance of waste if medication discontinued due to tumor progression

or toxicity

55


1. Enhanced patient services

2. Practice-payer partnership

3. “Learning system” model

4. Cost containment

5. Facilitated transformation

We want to develop a new model of collaborative care

56


Hospital providers need a new business model for financial sustainability

Private payers are Hospitals’ most profitable business…

…And they are a shrinking part of Hospital revenues

Medicare

Medicaid

Private Payer

70%

80%

90%

100%

110%

120%

130%

140%

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10

Aggregate Hospital Payment-to-cost Ratios

42%

35%

10% 6%

5% 3%

39% 38%

13%

1%

6% 3%

35%

39%

16%

2% 6%

2%

Private Payer Medicare Medicaid Other Government Uncompensated Care Non-patient

Distribution of Hospital Cost by Payer Type (% of Total Cost) - 1980 / 1990 / 2010

Breakeven

Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2010

58


172 clinics closed

323 practices struggling financially

o44 practices sending ALL patients elsewhere for treatment

224 practices acquired by a hospital

102 practices merged/acquired

As community oncologists migrate to hospital systems, cost increases

Source: COA Practice Impact Tracking Database

61


The “5 Step” Oncology Care Delivery Process…

ACO Benchmark

$$

$

Potential Savings

Potential Savings

Current Medical Costs

pmpm

MCC Value

IP admits $$$

ALOS $

ED $

EBM adherence

$$

ChemoTx $$

Radiology $$

Rad. Onc. $$$

Lab $

Self Mgmt. $

EOL Discussion

$

Hospice days

$$

% death in hospital

$

Office workflows with best pt. education & supportive care planning

Guidance on network partners for ancillary and adjunctive services, and expanded CM services

CDS tool use

1 2 3 Modeling Clinical Analytics Value Creation Plan

4 Delivery 5 Ongoing Collaboration

$

Actual Savings Shared

Negotiate Targets

50% to practice

50% to Aetna*

$

$

Project Implementation Plan

Data Personnel Workflow

Aetna

Practice

Measure

Refine

Measure

Design High Value Programs

Rigorous Measurement Across Individual ACO’s and BoB Drives Future Program Design

Aetna Facing ACO Facing

Capability Aetna Typical ACO Data Warehouse ✔ ✖ Technology stack ✔✔✔ ✖ Care Management Platform ✔✔✔ ✖

Risk Stratification ✔✔✔ ✔/✖ Identification ✔✔ ✔✔ Member Engagement ✔ ✔✔✔ Electronic Medical Record ✖ ✔✔✔ Real Time Management ✔ ✔✔✔ Population Management ✔✔✔ ✖ Reporting ✔✔✔ ✖

MCC

IP admits

ALOS

ED

EBM adherence

ChemoTx

Radiology

Rad. Onc.

Lab

Self Mgmt.

EOL Discussion

Hospice days

% death in hospital

62


…Can serve ACOs looking for oncology partners

Oncology Medical Home for Hospital / Health Systems

Hospital contracts with Aetna

to provide Medical Home

solution to its network

oncologists

1

Tools enable ACO to

benchmark community

practices

2

ACO engages oncology

practices in shared savings

arrangements or episode

based reimbursement

3

Oncology MH Solution:

+ Hospital System

A

Practice A Practice B Practice C

63


ACO

…Can prepare oncology practices for life in an ACO model

Oncology MH Solution:

Community Oncology

Practice

+ Text Text

Text

Text

Oncology

Practice

Hospital

Payor

Primary Care

Practice

Aetna contracts with

community oncology practices

to become medical homes

1 Aetna leverages ACS to

facilitate relationships

between enabled oncology

practices and ACOs

2

Enablement of oncology-specific component for ACOs B

64


EVIDENCE cost

66


Analytical performance: Is the quantification of the analyte(s) of interest reliable and reproducible?

Clinical validity: How well does the test relate to the clinical outcome of interest?

Clinical utility: Does the information provided make a contribution to and improve current optimal management of the patient’s disease?

Economic value: Assessment of cost savings and/or cost-effectiveness

Measures are interrelated Analytic performance must be evaluated in context of the clinical use

Clinical validity must be assessed in context of analytic performance

ASSESSING GENOMIC ASSAYS: ACCURACY AND CLINICAL RELEVANCE

67


Improve variant calling accuracy:

• Indels, CNVs, SVs, repeats

Fill in the holes:

• Targeted NGS panels miss a variable amount of content depending on genes

• Exome sequencing misses 5-10% of coding sequence

Need improved analytical validity of NGS

0

50

100

150 NGS Coverage Courtesy of Birgit Funke

68


Coding and IT Challenges/Opportunities

2011 CPT Code Description

Extraction of highly purified nucleic acid

Enzymatic digestion

Nucleic acid probe(s)

Mutation scanning by physical properties

Signal amplification of patient nucleic acid

Interpretation and report

83891

83892 (2)

83896 (12)

83903 (4)

83908 (4)

83912

2012 CPT

CPT 81350

2011 CPT Code Description

Extraction of highly purified nucleic acid

Enzymatic digestion

Nucleic acid probe(s)

Mutation scanning by physical properties

Interpretation and report

BRC/ABL MAJOR/MINOR/OTHER BREAKPOINTS

83891 (2)

83892 (2)

83896 (4)

83902 (2)

83912

2012 CPT

CPT 81206

Indication for use: Gleevec monitoring for CML (leukemia)

UGT1A1 Testing for Colorectal Cancer BCR/ABL-t(9;22) by RT PCR (Quantitative)

The conversion of stack CPT codes to specific codes will improve ability to track utilization, enable decision support tools, and enforce coverage policy

Indication for use: Irinotecan monitoring for colorectal cancer

UGT1A1 (UDP GLUCURONOSYLTRANSFERASE 1 FAMILY, POLYPEPTIDE A1) GENE ANALYSIS, COMMON VARIANTS (EG, *28, *36, *37)

70


PERSONALIZED APPROACH IN NSCLC

Figure: Massachusetts General Hospital, data on file Horn L & Pao W. J Clin Oncol. 2009;26:4232–5

K-ras

EGFR

B-raf

Her2

PIK3CA

ALK

MET

Unknown

Adenocarcinoma 1999 Histology-driven selection

Adenocarcinoma 2010 Targeting oncogenic drivers

72


Currently Five Biomarkers Are Required For Compliant Value Pathways Reporting

EGFR

BRAF

KIT

EGFR AKT1

KRAS PIK3CA

APC

EML4-ALK

NRAS

IDH1

AP2K1 PTEN

NOTCH1 TP53

ERCC1

CTNNB1

HER2

Drugs on the market with associated markers Markers associated with targeted

therapies increase over time

HER2

2000

EGFR

KRAS

ERCC1

2010

EML4-ALK

2010

AKT1

BRAF

KIT

PIK3CA

APC NRAS

IDH1

AP2K1 PTEN

NOTCH1 TP53

CTNNB1

2015

ER / PR

Biomarkers in orange are elements critical to successful reporting for Value Pathways Powered by NCCN

74


No matter how much we do…

76


Variations in end-of-life care: Dartmouth Atlas of Health Care

Percent of decedents enrolled in hospice during the last 6 months of life (2003-2007)

*Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression.

Arizona: 54.5%

New York: 23.8%

• US State

Proprietary & Confidential 78


Advanced Care Planning Prompt

79


• Care management by specialty trained nurse case managers to handle physical, emotional, spiritual and culturally-diverse needs of patients in advanced stages of disease

• Provides :

– Advanced planning, directives and support

– Emotional support and pain management

– Choices, alternatives, use of hospice care

Aetna Compassionate Care Results: Medicare Program transposes traditional acute and hospice numbers

- 81% of Medicare members in Compassionate Care Program elected hospice care

- 18% deaths in acute or sub-acute facilities - 82% reduction in acute days, 88% for intensive care days - High level of member and family satisfaction

Specialized Care Management Program: Aetna Compassionate Care

80


Oncology Practice Executive Summary: Payment Models

Financial incentives that reward providers for the achievement of a range of payer and provider objectives, including delivery efficiencies, submission of data and measures to payer, and improved quality and patient safety Need to develop sophisticated inventive program to allow MSKCC-Aetna relationship to work: 1) MSKCC enterprise level 2) Physician practice level

Traditional Fee-For-Service

Provider(s) paid on the basis of volume of services

Fee-For-Service Shared Savings

Oncologists paid on a FFS basis deliver care against a preset group of quality and cost benchmarks to determine shared savings at practice level

Episodic Bundling

Monthly payment for some services + FFS, delivered to a patient for a specific condition over a defined period, with shared savings recoupment (minus PMPM)

Global Payment

Bundled payment for some or all services delivered to a patient for an episode of care for a specific condition over a defined period

Bas

e P

aym

en

t In

cre

me

nta

l P

aym

en

t

Traditional Fee-For-Service

Pathway Programs with Shared Savings

Oncology Patient Centered Medical Home

Bundled Payment per Disease and Episode

Pay For Performance (P4P)

Today’s Payment Mechanisms Evolving Payment Mechanisms

Payer $ Risk

Provider $ Risk

The shift from fee-for-service to value-based payment models is changing the risk profile.

New physician-payer collaborations are forming to be better able to bear risk

Timeline: executed over 3 years

We are here

81


http://commons.wikimedia.org/wiki/File:Mendenhall_Glacier.jpg


The right alignment of stakeholders drives the best possible patient outcomes

PLAN SPONSOR – PROVIDER Incentives based on quality

Decision support technology

NATIONAL NETWORK ACCESS PROVIDER - PAYER Plan design steerage to quality

and efficiency

83

Copyright © 2014 by Atlantic Information Services, Inc. All rights reserved. Reproduction by any means — including photocopy, FAX or electronic delivery — is a violation of federal copyright law punishable by fines of up to $150,000 per violation.

Atlantic Information Services, Inc.

Current State of Cancer Care Has ChallengesReprinted from the March 2014 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

With enormous resources available to researchers, experts know more about cancer than ever before. Oncology drugs — many of which are targeted therapies that are indicated for people with specific genetic markers — dominate the pharmaceutical pipeline. To a large extent, cancer is no longer the death sentence that it once was, as “two-thirds of Americans now live at least five years after a cancer diagnosis as compared to only about half in the 1970s,” says the American Society of Clinical Oncology (ASCO). But that innovation comes with much higher costs for care. Various other factors are impacting the current cancer care environment, and ASCO’s recently released The State of Cancer Care in America: 2014 offers a view of those.

According to ASCO, which represents almost 35,000 oncologists and oncology profes-sionals, new cancer cases will increase by 45% by 2030, as cancer becomes the leading cause of death in the U.S. At the same time, increased survivorship will mean a large population of people who “will require significant, ongoing care,” says the report.

Its findings include the following:u With the 18 cancer treatments that the FDA approved last year, that brings the total number of anti-cancer drugs to more than 170.

u The cancer death rate in the U.S. has decreased 20% since the early 1990s, and there are 13.7 million cancer survivors in the country.

u Annual costs for cancer care are expected to be more than $173 billion in 2020, up from $104 billion in 2006.

u The share of oncologists who are at least 64 years old surpassed the proportion of ones who are less than 40 years old in 2008, which is the first time that’s happened. This gap continues to widen, with the medical oncologists being slightly older than the general phy-sician population, a consistent trend for the last eight years.”

u Most oncologists are in urban areas, but about 19% of Americans live in rural areas. “More than 70 percent (2,067) of the U.S. counties analyzed had no medical oncologists at all.”

u From 2012 to 2013, payer mix was fairly stable. In 2013, commercial payers represented 36.09% of payers, Medicare was 48.42%, Medicaid was 11.4%, and 7.28% was uninsured/self-pay.

u In 2012 and 2013, payer pressures and cost pressures were the main pressures practices cited, followed by competitive pressures.

ASCO offers the following recommendations to help ensure oncology care is available:u “Identify creative strategies for leveraging the oncology workforce.”

u “Leverage technology and innovative practice models.”

u “Monitor and address physician burnout.”

u “Monitor and address the size and diversity of the oncology workforce.”

84



The group also recommends the following actions to help oncology care providers meet patient needs:u “Payers should align payment systems with the goal of delivering high-value, patient-centered care.”

u Policymakers should “test a range of promising cancer care delivery models that address the unique challenges of treating the disease.”

u Policymakers should “reduce instability in federal payment systems,” including re-pealing the Sustainable Growth Rate formula and reversing sequestration-caused cuts to Medicare.

While the report is the first one on the state of cancer care that ASCO has published, the association says it will produce annual updates to it.

To download the report, visit www.asco.org/stateofcancercare. G

Highmark Will Push Back on Pricing for Cancer Drugs in Outpatient SettingReprinted from the March 2014 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

Although site-of-care optimization is certainly not a new approach to help control the costs of specialty drugs, health plans generally have applied the tactic to oncology therapies. But that will change on April 1, when Highmark Inc. will attempt to counter rising costs of oncology care services by eliminating markups. The Blues plan says it expects the billing change will save more than $200 million annually — and will not impact the quality of care members receive.

Highmark will apply the approach to infusible chemotherapy drugs administered at hospitals in western Pennsylvania. The plan has changed the payment methodology through updating hospital contracts in eastern Pennsylvania, Delaware and West Virginia, says spokesperson Aaron Billger. But in western Pennsylvania, “old hospital contracts” are in place. In fact, he says, the plan has a “long-running…contract dispute with one large health system.…They refuse to talk to us,” he tells SPN. Highmark’s billing of drugs “in the same fashion no matter where [care is] delivered…is well within the confines of these contracts.”

“One of the things that’s happened through the transformation of health care is the con-solidation of health care providers continues at a rapid pace,” Billger says. According to a report by the Community Oncology Alliance that was issued in June 2013, out of 1,338 com-munity oncology practices, 469 had either entered into an agreement with a hospital or been acquired by one. In addition, 288 clinics had closed, and 469 were experiencing financial problems. Forty-three practices said they were sending all of their patients to another site for treatment, and 131 practices had merged with other ones or been acquired by a corporate entity that is not a hospital.

It doesn’t look like the consolidation trend — and thus the increase in prices — will ease up any time soon, if a recently released report by the American Society of Clinical Oncology (ASCO) is any indication. According to ASCO, as the administration of health care services shifts from physician practices to hospitals, this “represent[s] potential disruptions of care

85



— as fewer patients receive treatment from their own physicians’ staff — and also raise[s] concerns about cost. Chemotherapy administration in hospital outpatient departments is usually reimbursed at higher rates than in physician practices.”

The ASCO report, titled The State of Cancer Care in America: 2014, contains the following data:u In a 2013 ASCO member survey, 26% of responding oncology practices said that an af-filiation with a community hospital in the coming year was a likelihood. That percentage was only 15% in 2012.

u In 2011, 33% of fee-for-service chemotherapy administration was done in hospital out-patient departments, up from 13.5% in 2005.

u “From 2005 to 2011, Medicare payments to hospital outpatient departments for chemo-therapy administration tripled (from $98.3 million to $300.9 million), even as spending for the same service in physician offices decreased” from $507.5 million to $433.8 million, a drop of 14.5%.

u Half of the respondents to the 2013 member survey said they “sent some of their Medi-care patients elsewhere for chemotherapy — primarily to hospital outpatient departments — as a result of declines in Medicare reimbursement for cancer treatments after the federal budget sequester.”

‘Irrational Billing’ Is Issue

On the one hand, Billger tells SPN, consolidation of providers “helps coordinate care better,” such as when creating accountable care organizations. But “at the same time, it cre-ates opportunities for the manipulation of billing,” which has resulted in “irrational billing. In the hospital, there is one price, and in the doctor’s office, there is another price. There needs to be parity.…If we bring parity,…the drug is the drug is the drug no matter where it’s administered.”

Bill Sullivan, principal consultant with Specialty Pharmacy Solutions LLC, explains that once a hospital system purchases a community practice, “reimbursement for the physicians often skyrockets based on the hospital’s usually more generous contractual terms. These reimbursements can be as much as three or four or five times the rate of reimbursement for the exact same services the day before the practice was purchased. Not surprisingly, payers have taken notice…and they are ready to start pushing back.”

Highmark, says Sullivan, is “ready to go to the mat to restructure payments to hospitals and, in particular, reduce reimbursements for staff-physician office-based services.

“To be sure, they will also want to cut payments for outpatient infusion services…which have similarly skyrocketed as the now-employed physicians refer their patients to their hos-pital’s outpatient department versus infusing in their offices.”

Billger points to a recent vote by the Medicare Payment Advisory Commission (MedPAC) to recommend to Congress that reimbursement for some health care services be consistent across all sites of care. That recommendation is expected to be included in a MedPAC report released this month.

Plan Will Not Change Drug Administration

Highmark is “addressing the drug cost” by “bringing similar pricing to drugs” re-gardless of where they are administered. Billger clarifies that the plan is “not doing any

86



adjustments to the administration of the drug.” For example, he says, if a physician deter-mines that he or she needs three people to help with administration, Highmark won’t ques-tion that. “But the drug should be the same price no matter where” a person receives it. “The last three to four years, we’ve seen these drug prices triple,” he says.

But with the new pricing system in place, a Highmark member with lung cancer could save between $1,000 and $3,500 for a single treatment, says Billger. He explains that Highmark is “changing how providers can bill the drug.” However, this “will not impact patient care.”

The Blues plan, says Billger, is the “steward of our customers’ premium dollars.…We are safeguarding our members from irrationally high health care costs.”

The approach is a “regional solution to a national problem,” he maintains. So it’s not sur-prising that Highmark has “heard from health plans who are facing the same issues” and are “looking for best practices to consider following.”

Specialty Pharmacies Could Benefit

The tactic, says Sullivan, is important to specialty pharmacies.“It means a leveling of the playing field and a willingness on the part of payers to push

members to community-based home infusion. For specialty pharmacies that are also ac-tive in specialty infusion, the welcome mat may be out for providers that offer a better value proposition.”

However, the move to equalize pricing across sites of care has “received mixed responses from physicians,” admits Billger.

“But progressive-thinking physicians understand this is the thing to do.…They under-stand that everyone plays a role in controlling health care costs.”

For more information, contact Billger at [email protected] and Sullivan at [email protected]. G

Cancer Patients, Physicians Are Reporting Issues With ExchangesReprinted from the February 2014 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

Although health insurance exchanges have been live for just a little more than a month, one association has heard from oncologists and cancer patients alike that there has been some disruption of care. In response, the Community Oncology Alliance (COA) has formed a working group to try to determine the extent of the issues and then disseminate informa-tion about them to providers.

Soon after the start of exchanges, an early trend was that with “insurers making net-works very narrow, we’re seeing practices left out of networks,” says Ted Okon, executive director of COA. In addition, “individual physicians within practices are being left out of networks for no reason,” he says. This can be particularly difficult for people already under-going treatment for cancer who now find that their oncologist is out of network — exactly the situation that Sen. Tom Coburn (R-Okla.) said in late January had happened to him,

87



points out Okon. Coburn had been undergoing treatment for prostate cancer and is now paying out of pocket to continue seeing his oncologist.

More recently, Okon tells SPN, we’re starting to see patients coming in for treatment…and realizing their oncologist is not in their network or patients coming in with a plan that has some restrictions” on coverage — perhaps certain aspects of care are not covered or must be approved ahead of time. In addition, “reimbursement for oncology practices has really been cut down,” he says. He knows of a situation in New York in which the hospital that a practice is affiliated with is not in the plan. Some patients “basically require hospitalization” for their care. But “all of a sudden, these physicians can’t get their patients in the hospital.”

Overall, he says, “it is really a mixed bag” of effects.And this is just what he’s hearing now. Down the road, Okon says, “we’re going to see

issues with when someone, particularly a younger person, gets a diagnosis of cancer, they’re going to run right away to the exchanges for coverage.” That, in turn, will lead to “the issue of when the coverage started” and who is responsible for what coverage. People in exchanges “are going to realize just how expensive” coverage is, says Okon, who says he’s seeing high coinsurance for some treatments such as oral cancer agents.

So at COA, “one of the things we’re trying to do is put up a way of tracking this and see-ing all the things that are happening,” he says. “We know there are certain things happen-ing already, but we can’t quantify them.” The working group will determine “how best can we identify the issues and then quantify them.…It’s clear we’re seeing some things already, but we’re just not clear on the extent” to which they are occurring. If COA determines that the issues are not that widespread — the outcome Okon says the group is hoping for — it can work on a one-on-one basis with practices, but if they are more systemwide, then that could mean that the group would reach out to Congress “to fix some of the holes....Pure and simple, where there are problems, we want to get them solved,” whether it means working with health plans or Congress or another stakeholder, he says. “We do not want cancer patients that cannot get treated or cannot complete treatment.”

In addition, COA wants to “help and protect practices” affected. One way the association is doing that now is by “putting practices in touch with each other.” In particular, if a prac-tice is able to solve a problem, COA wants to “get that information out” so other practices with the same issue could hopefully take the same tack. And the group also wants to let pro-viders know what may be coming based on other practices’ experience.

“We want to get the information and disseminate it,” Okon says. “Now, there’s more that we don’t know than we do know.”

Contact Okon through Bo Gamble at [email protected]. G

Express Scripts-RainTree Deal Targets Oral Oncolytics’ DispensingReprinted from the December 2013 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

Express Scripts Holding Co. recently unveiled a novel deal with RT Oncology Services Corp., a group purchasing organization (GPO) for community oncology practices known as RainTree, that should benefit all stakeholders involved.

88



Under the three-year agreement, RainTree oncology practices that dispense oral drugs will become part of Express Scripts’ pharmacy network, which will allow them to continue providing those drugs to their patients beyond the first one or two fills. Patients will ben-efit from the continuity of care, as well as from adherence programs provided by Accredo, Express Scripts’ specialty pharmacy.

The practices will be able to increase their revenues by dispensing these drugs, which represent almost 40% of cancer drug use and are the fastest-growing category of oncology medications, says Mike Martin, president and CEO of RainTree.

“Orals are an increasingly significant part of the oncologists’ business and are important to their long term viability,” says Warren Dodge, senior vice president, OBR, an oncology-focused news and information resource.

According to an interview that OBR Oncology did with Jeff Patton, M.D., chief medical officer and founder of RainTree, “Right now in community oncology, roughly 20-30% of pre-scriptions flow through Express Scripts.” About 50 oncology practices and 700 oncologists are in the RainTree network, he said.

Brian Henry, a spokesperson for Express Scripts, notes that “RainTree uses its size and scale to negotiate with payers for network participation on the medical benefit and with wholesalers and manufacturers for discounts on drugs. It shares our goal of making the use of prescription drugs safer and more affordable.”

“Oncology GPOs and distributors are typically owned by the same wholesaler — McKesson Corp., AmerisourceBergen Corp. and Cardinal Health,” explains Dodge. “If you select the GPO, then you are tied to their distributor and vice versa. I join the GPO and purchase from the distributor. Practices will occasionally leave one GPO/distributor for the other, if they believe they can get better prices and/or services.”

However, Dodge tells SPN, “RainTree is a new kind of oncology GPO, initially focused in oral oncolytics, in addition to providing other clinically relevant solutions. The GPO has more teeth in that the practices have made significant multiyear commitments, which allows RainTree to negotiate more effectively on their behalf. Physicians like businesses owned and managed by other physicians. While RainTree has a lot of outside capital and can only have partial physician ownership, it resonates well with the docs.”

Henry tells SPN that his company entered into the arrangement because “we operate in a complex environment in specialty, and these agreements allow Express Scripts and Accredo to better compete today and be more flexible to adjust to future market changes.”

The agreement, Henry says, “allows us to implement our clinical expertise and under-standing of the specialty space to improve the performance of community oncologists who have pharmacies.” He explains that “our Accredo clinical programs will be adopted by the RainTree pharmacies. We will be able to better coordinate care at those pharmacies, apply our safety checks and monitor for fraud, waste and abuse just as we do across other network pharmacies. With high-priced cancer drugs, this capability to identify and drive out waste is even more important than ever.” The upshot, he says, is that Express Scripts clients will ben-efit from the deal because it “will add predictability in working with community oncologists and can help drive additional cost savings while preserving better health outcomes.”

The arrangement “is important for oncology practices, cancer patients, payers and manufacturers,” contends Elan Rubinstein, Pharm.D., founder and principal of consulting firm EB Rubinstein Associates. “There are more and more oral cancer drugs, and [there is]

89



a continuing concern about disconnect in their proper use and monitoring,” he tells SPN. “Practice-based pharmacies can address this and can also give practices dealing with declin-ing infusion suite utilization a business boost.”

According to Rubinstein, “For a cancer patient, particularly for one not yet in remission, other medical conditions become secondary. With remission, other medical conditions may remain secondary in the patient’s mind.” For those reasons, he says, “the cancer practice retail pharmacy may become a patient’s main pharmacy, not only for cancer-related medica-tions,” which is “something of a medical home concept. You can easily see how this restruc-tures and rationalizes cancer care — and, if so, reimbursement could follow suit.”

Contact Henry at [email protected], Dodge at [email protected] and Rubinstein at [email protected]. G

Start Palliative Care at Time of Cancer Diagnosis, Not End of LifeReprinted from the December 2013 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

Within oncology, the two biggest cost drivers of cancer are “treatment that doesn’t meet the goals” of the patient and the “absence of community-based support,” contended Amy Berman, senior program officer at the John A. Hartford Foundation, speaking at the American Journal of Managed Care-sponsored conference Patient-Centered Oncology Care: Real-World Perspectives on Nov. 15. The value proposition, she maintained, is to provide the “same or better care at the same or lower costs.”

Care should focus on “person-centered goals,” she said, but “how can care be patient-centered when we don’t discuss serious illness with the patient?” One important aspect of that, said Berman, is palliative care. When a person is diagnosed with a serious disease, that is the time that palliative care should begin, she contended. A nurse who is a geriatrics ex-pert, Berman spoke not only from that point of view but also from the perspective of a pa-tient: She was diagnosed with stage IV inflammatory breast cancer three years ago.

Too often palliative care is initiated at a time in a person’s illness that essentially ren-ders it end-of-life care. But by beginning palliative care earlier, the patient’s care can really be focused on the patient because it can take into account his or her preferences and values. Person-centered care, said Berman, “makes the patient an integral part of the care team who collaborates with the health care professional in making clinical decisions.”

In fact, according to the recent Institute of Medicine report titled Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, “engaged patients” are a critical as-pect of how to improve cancer care.

So when Berman was diagnosed with this rare form of breast cancer that also has a par-ticularly bleak outlook — only 11% of people with a stage IV diagnosis survive five years — she was determined to follow the so-called Niagara Falls trajectory. She wanted to have a good quality of life for as long as possible and then drop off the cliff, as opposed to dropping off the cliff at the beginning of treatment and going to the same endpoint.

Before the diagnosis, Berman had discussed with her initial physician what she wanted to do depending on how advanced the cancer was. After learning the cancer had spread to

90



her spine, she visited a specialist, who told her, “This is what we’re going to do” rather than discussing her treatment with her. He wanted to start with “the most aggressive chemo-therapy we can do,” followed by a mastectomy, then radiation and then more chemotherapy. When she asked why a mastectomy was in order since the cancer had already spread, he responded, “You don’t want to look at the cancer, do you?”

So Berman went back to her initial physician. She is undergoing chemotherapy “with the least side effects” and takes one pill every night and has an infusion once a month. And she’s doing very well — well enough that she is still working, regularly jet skis and has climbed the Great Wall twice since her diagnosis. And she estimated that she’s saved about $500,000 in health care costs over three years by opting for this regimen.

“Palliative care shifts care out of the hospital and to the home,” but oftentimes that care is still given in the hospital, so community-based palliative care is critical. Palliative care, she asserted, is “an extra layer of support” in a health care system that has a lot of “liability-driven care.”

View the report at www.nap.edu/catalog.php?record_id=18359. G

Overadherence With Oral Cancer Drugs Can Cause Health, Financial, Waste IssuesReprinted from the November 2013 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

Keeping patients adherent to their medication regimens is particularly important with oral oncolytics. The therapies, after all, treat life-threatening conditions, and potential waste of these costly drugs could cause a pretty big financial hit. But while many specialty phar-macies and health plans focus on making sure that people don’t miss a dose, taking the drugs too often can be just as much of a problem. And with a growing number of oral oncol-ogy products becoming the treatments of choice over therapies that previously were admin-istered by physicians in hospitals or provider offices, patient overadherence — particularly with complicated treatment regimens that may require them to go on and off the therapy at certain intervals — may be an increasing area of concern.

A study in the October 2013 issue of the Clinical Journal of Oncology Nursing found that 33 of 100 patients taking the oral oncology drugs Xeloda (capecitabine), Tarceva (erlotinib), Tykerb (lapatinib), Gleevec (imatinib), Temodar (temozolomide) and Sutent (sunitinib) were nonadherent to their treatment regimens. Of those 33, only 13 were underadherent while 20 were overadherent.

Among the overadherent patients, the more complex the treatment regimen, the more issues with dosing they had. Forty-eight of the 100 people had a regimen classified as “com-plex,” meaning that their dosages fluctuated during the study time or they cycled on or off medications. Among this group, regimens were classified as continuous, 14 days on and seven days off, seven days on and seven days off, and other.

Of the 48 people with complex regimens, the following results were found:u Among six patients with continuous dosing, one was overadherent.

u Of the 25 people with a cycle of 14 days on and seven days off, 12 were overadherent.

91



u Out of nine patients on a seven-days-on/seven-days-off cycle, six were overadherent.

u Among eight people in the “other” category, one was overadherent.

“Overall, we were surprised by the amount of overadherence observed in the study, but it is important to note that this is an exploratory study at one site,” says Ann McNamara, Pharm.D., clinical development manager at Fairview Pharmacy Services, LLC. “Practices and processes at one site may be very different than at other sites. The study did, however, reinforce the importance of being vigilant in monitoring patients receiving complex oral chemotherapy regimens.”

Overadherence to oral oncolytics can pose a litany of problems. Patients’ health may suf-fer because “chemotherapeutic agents by their very nature can be toxic,” says Ron Smith, Pharm.D., chief operating officer for Biologics, Inc. “Patients that take more medication than is intended by their provider run an increased risk of significant adverse effects that can result in early discontinuations of the therapy or increased health care utilization such as emergency room visits.”

According to McNamara, “The dangers of overadherence are related to the specific che-motherapeutic agent and degree of overadherence. Taking medication for an extra day of a cycle versus taking two doses in a day will present different dangers.” Potential problems, she tells SPN, include “increased bone marrow suppression; skin toxicities (e.g., hand-foot syndrome); gastrointestinal toxicities (nausea, vomiting, anorexia, constipation, diarrhea), which could potentially lead to dehydration and/or bowel infarction; and cardiovascular [problems including] hypertension, prolonged QTc interval leading to torsades de pointes.”

Moreover, says Jeremy Schafer, senior director, specialty solutions at Prime Therapeutics LLC, “an overadherent patient will also run out of medication sooner and be unable to get additional medication.” When a therapy is discontinued early, says Smith, “This may lead to premature progression to other therapies or interventions that can result in additional, un-necessary cost.”

Another risk, points out Jessica Lea, Pharm.D., president of Tria Health, is that payers may “wonder about fraud and abuse as well if you are unable to know whether the patient has actually taken the med or is just filling the med through their benefit plan and reselling the product.”

The financial impact for both payers and members can be significant with overadher-ence. Schafer points out that “more adverse events for the member could lead to subsequent therapy or hospitalization, both of which add costs for payers” as well as members, who also “may need to pay out-of-pocket costs to get medication faster if their health benefit doesn’t allow for early refills.…Additionally, if the member fails therapy due to overadherence, the payer will have wasted money on a treatment regimen that could have led to a positive out-come if done correctly.”

Oncology Often Has Complex Regimens

Schafer tells SPN that “complex regimens are common in oncology and of crucial impor-tance. Complex regimens are often designed to maximize effect on the tumor but also give the body a chance to recover from the toxicity of the medication. A patient that is overad-herent is likely to experience more adverse events as the body does not get a break from therapy.”

92



“Oral chemotherapy regimens tend to be very complex and involve cycling of medica-tions throughout the month,” says Lea. “Many regimens require patients to take certain medications for certain days of the month, with the potential for weekly and even daily vari-ations in their regimen and/or dosing. As these regimens involve medication with poten-tially life-threatening side effects, it is imperative to ensure that patients understand proper dosing and have the ability to manage their own medications.”

According to McNamara, “Oral chemotherapy regimens with FDA-approved cyclical dosing include Pomalyst (pomalidomide), Revlimid (lenalidomide), Sutent, Temodar and Xeloda. Xeloda and Tykerb are prescribed concomitantly for breast cancer. In addition, many patients are taking oral agents while receiving IV chemotherapy, adding additional complex-ity to the protocol.”

Smith adds that “many therapies also have dosing schemes that require dosing modifi-cations based on response and side effects. This can be challenging for a patient who is not being actively monitored to understand when it is appropriate for modifying their dosing regimen.”

An interesting point about the study, McNamara points out, is that “seven on, seven off is not a FDA-approved regimen for any of the medications listed. The authors did not comment on whether this regimen was used for just one oral chemotherapy regimen. Our pharmacists do see Xeloda prescribed seven on, seven off; this non-FDA-approved dosing is sometimes used by the prescriber to minimize side effects.”

So which stakeholders need to be working to mitigate any potential adherence issues?“The priority of everyone involved in health care should be to take care of the patient,”

Smith says. “It is important that all health care stakeholders make a collaborative effort to ensure members have the tools and educational resources needed to comply with their therapy.”

He contends that “drug manufacturers need to continue publishing results early and educating the health care community about therapies in development.…Open dialogue throughout a patient’s therapy” between physicians and pharmacists helps ensure “that communication is not misinterpreted. Finally, health plans and the entire health care com-munity need to recognize the way care is delivered is evolving. It is important that they adapt and create benefit designs accordingly. It’s important that health plans recognize the need for more personalized support in the home setting, and that pharmacists and physi-cians take a more proactive approach in making sure members understand their therapy.”

Patient Communication Needs to Be Consistent

Kari Amundson, director, specialty pharmacy development at Fairview, contends that “there needs to be a collaborative effort among stakeholders to deliver and reinforce clear and consistent messages to patients. Consistent messages are vital to prevent patient confu-sion. For example, pharmacists at the specialty pharmacy assess and confirm patients un-derstand the medication protocol ordered and are able to follow it. In order to do this, there needs to be proactive communication with the oncology clinic and the specialty pharmacy as to what instructions the oncology clinic provides to patients. Patient education materi-als provided by manufacturers should be reviewed by the specialty pharmacy to confirm information provided to patients is consistent with their own. Finally, specialty pharmacies should coordinate with health plans and their case management programs to verify patients receive consistent information.”

93



Amundson asserts that “the specialty pharmacy is best positioned to ensure health plan members are taking oral chemotherapy medications correctly. Pharmacists provide compre-hensive counseling to get patients started out right on the new medication,” which includes educating them on appropriate use of the drug “and what to expect, including explanation of the dosing regimen, potential side effects and strategies to minimize them, and when to call a health professional.”

Ongoing nurse-administered therapy management programs that “provide ongoing patient assessment, adherence and side-effect monitoring, as well as proactively identify opportunities to triage to pharmacists, physicians or financial advocates as necessary to maximize adherence, outcomes, and safety” are important, she says. “As therapy continues, these therapy management nurses promote adherence by developing trusting relationships with patients that positively influence behavior. At Fairview Specialty Pharmacy, we find when patients establish relationships with these nurses, they confide in them in cases where they typically may not have alerted a member of the health care team,” such as with certain side effects or nonadherence with therapy. “In these cases, our nurses have successfully con-vinced patients to contact their physician and thus avoid more serious side effects, such as severe constipation leading to bowel infarction. When noncompliance is identified, nurses can use the information provided by the patient to develop individualized solutions tailored to address the issue. “

When it comes to overadherence and underadherence, “I have found that the under-standing and measurement of underadherence is more mature within the industry,” says Smith. “Most specialty pharmacies have robust monitoring programs that are able to iden-tify potential underadherence based on utilization data. With overadherence, the use of data becomes more unreliable and harder to predict. It takes strong engagement and a close rela-tionship with the patient to avoid potential overadherence.”

View the Clinical Journal of Oncology Nursing article at http://tinyurl.com/kutlwbl. Contact Amundson and McNamara through Amundson at [email protected], Schafer through Karen Lyons at [email protected], Smith at [email protected] and Lea at (888) 799-8742. G

Clinical Pathways Reduced Costs of Care 15%; Success Led to Medical Home PilotReprinted from the June 2013 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

When P4 Healthcare LLC launched its first clinical pathways program with CareFirst BlueCross BlueShield in 2008 (SPN 4/09, p. 8), its goals were to help rein in cancer care costs without sacrificing patient outcomes and get physicians on board by providing fair reim-bursement. At the time, to say this was a tall order may have been an understatement, as payers traditionally had been very hands off when it came to oncology.

While P4 — whose parent company, Healthcare Solutions Holding, LLC, was purchased by Cardinal Health, Inc. in 2010 (SPN 7/10, p. 1), making P4 part of Cardinal Health Specialty Solutions — and CareFirst have released data showing the savings from this program, a recent study provided third-party validation of those benefits. Additional studies from

94



Cardinal and CareFirst — as well as a medical home pilot program the two are partnering on — have demonstrated that the program is meeting its goals.

When the program started, it focused on breast, lung and colon cancers, which made up the bulk of CareFirst’s oncology costs. Cardinal and CareFirst compared claims from January 2007 to December 2010 for patients with these cancers who were treated by phy-sicians in the pathways program with a control group identified by Truven Health’s MarketScan database. The findings show that CareFirst reduced its overall costs to treat these cancers by 15%.

“The overall reduction in hospital services was 7%, through a combination of decreased ER visits, decreased hospital admissions and decreased length of stay,” explains Bruce Feinberg, D.O., chief medical officer, oncology for Cardinal Health Specialty Solutions. “We believe one of the key factors leading to fewer ER visits was the more appropriate use of medications — particularly chemotherapy.” He adds that while the company does not have specific information as to the lengths of stay, “we intend to measure and report that level of detail in future studies.”

According to Feinberg, “The biggest surprises [among the studies’ findings] were around physician behavior and reimbursement. Despite the accepted dogma that physician prescribing will follow their economic interest, we found that doctors could be paid more but prescribe less and that they could be paid less for drugs and prescribe the same. We see this as reinforcement that the evidence-based pathways were the driver of the physician be-havior, not the drug reimbursement.”

He tells SPN that physician “participation has been excellent in the community, upwards of 85% including both salaried and academic practices.” Of note, he says, is that “85% of community oncologists in the network participate, but those doctors represent 95% of com-munity oncology cancer spend.”

Participation in the clinical pathways programs is “collaborative and voluntary,” points out Feinberg. His company is working on other programs with various plans across the country, “and each has financial incentives for participation, above and beyond historical reimbursements. Incentives vary from fee schedule enhancements to participation bonuses to shared savings. We encourage reimbursement methodologies that incent providers to participate and comply with clinical pathways.”

During the second year of the pathways program, CareFirst expanded it to 10 can-cers, including prostate, ovarian, lymphoma and myeloma, notes Feinberg. In addition, in December 2011, CareFirst and Cardinal launched the first clinical pathways program for rheumatoid arthritis (SPN 12/11, p. 11), which also has proven successful (SPN 5/13, p. 1).

Organizations Launched Medical Home Pilot

Following the initial pathways program’s success as measured in financial savings and physician participation and compliance, the two organizations launched a medical home pilot program in January 2011, “with the hope of further decreasing cancer care costs while continuing consistency and quality of care,” according to an abstract (#e17582) of a study presented at the recent American Society of Clinical Oncology meeting. The new program “offered a new physician reimbursement model that shifted the source of revenue from mar-gin on drug sales to cognitive services allowing physicians to focus on optimal patient care without the financial incentive to prescribe chemotherapy. Physicians were encouraged to commit to an intensive continuous quality improvement (CQI) program, which included an

95



end-of-life [i.e., EOL] initiative and a post chemotherapy nurse call-back program that would lower costs by decreasing emergency room and hospital admissions.”

Physicians who had participated in the initial pathways program were eligible to par-ticipate in the medical home pilot. Fourteen practices with 31 physicians joined the pilot. The study compared data from the pilot with data from 103 physicians from 39 practices who were not participating. And although all cancers were included in the medical home program, “for the purposes of this study, we measured compliance only for breast, colon and lung cancers,” says Feinberg.

Findings from the study showed that the medical home provided gross savings of $2.0 million compared with the first program. “Significant savings can be achieved in a provider group already compliant with a mature pathways program,” concluded the study.

“Most of the savings was driven by a reduction in hospital events, and some savings were also created by drug margin change due to the rise in ASP [i.e., Average Sales Price],” explains Feinberg. “However, participating practices were promised to be made whole on drug margin delta.”

Another study looked at the potential cost savings of a CQI program. Of that study, Feinberg says that “the two outcomes that stand out are related to nurse surveillance and end-of-life awareness. Nurse calls likely prevented five to 15 ER visits and three to 10 hos-pitalizations. The EOL program raised awareness of EOL options and best practices, in-creasing hospice referrals to 80%. However, short lengths of stay in hospice (seven days or less) and high hospitalization rates leave room for improvement.”

That study also revealed that only one patient out of 15 — which was out of 38 patients receiving clinical interventions that involved a return visit to the provider office — received chemotherapy within 14 days of death. “This is significant because it challenges dogma as do many of the observations in this research,” Feinberg says. “Doctors did not change their care despite a dramatic change in reimbursement method. Chemotherapy was not a major expense at end-of-life — hospitalization was.”

Contact Feinberg through Tara Schumacher at [email protected]. G

Molecular Diagnostics Initiative Should Improve Care, Reduce CostsReprinted from the June 2013 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

As molecular diagnostics becomes more important in the treatment of cancer, a new partnership hopes to bring some efficiency and clarity to a field that is evolving quickly. McKesson Specialty Health has selected med fusion and Foundation Medicine as the pre-ferred diagnostic laboratories for The US Oncology Network, the division of McKesson Corp. said May 30.

The motivation behind selecting preferred labs, says Catherine Swick, senior director of lab services and precision medicine for McKesson Specialty Health and The US Oncology Network, was due to the fact that the company “recognized a few things.” First is that there is an “increasing amount of testing in oncology care,” which can make it hard for physicians to determine what test is needed, she explains. Working with the companies will “increase

96



consistency” and offer “guidance as to what is appropriate and when.” In addition, there continues to be an increase in molecular testing of actual mutations, so it’s important for physicians to really be on top of this, Swick tells SPN.

Clinical Trials Are Important Aspect of Deal

Clinical trials were another consideration for McKesson Specialty. “Clinical trials are really an important part of oncology care,” giving many patients “access to lifesaving treat-ments,” contends Swick. She notes that more clinical trials require testing just for patients to be involved in them. With the molecular diagnostic data provided electronically to McKesson Specialty, the firm can populate its electronic health network and can search those files to find out which patients may be eligible for particular trials.

One of the country’s largest networks of community-based oncologists and integrated cancer care practices, The US Oncology Network also has “a robust research network within its larger network,” notes Marcus Neubauer, M.D., medical director of oncology services for McKesson Specialty Health and The US Oncology Network. The physicians now will be “given the opportunity to help design panels.”

Initially, “the feeling was we wanted to partner with one company, but it turned out to be two,” says Neubauer. He explains that there are “many companies out there with high variability in a lot of things,” including how they run tests and even which tests they use. “There is a lot of difference of opinion in what the tests mean and how they apply to practic-ing physicians.”

There are essentially two types of molecular diagnostics. A panel provides informa-tion on multiple genetic markers based on one test on one sample. For example, Neubauer says, in non-small cell lung cancer, a panel looks at eight or nine different markers. Second is next-generation sequencing, which Neubauer calls the “future of molecular diagnostics.” It’s also the reason why McKesson Specialty is partnering with two companies. Foundation Medicine “is a leader in this area,” he contends. Its FoundationOne “offers a fully informa-tive genomic profile useful in many cancer types and clinical scenarios.…Most labs, includ-ing med fusion, do not do this at this time.”

Med fusion will complement Foundation Medicine because of its “logistical capabilities and broad clinical testing menu,” according to McKesson Specialty. In addition, it will func-tion as the “diagnostic gateway for The US Oncology Network,” explains Swick. Nowadays, practices may send samples out to “20, 30, 100 vendors.…The technology interface to get all that data can get complicated.” But now, “all testing goes through med fusion, which can send it out” to labs if needed. “All data comes back through med fusion, which helps ensure that redundant testing isn’t done,” she explains. In addition, a more efficient process should mean better turnaround times on results.

Neubauer notes that med fusion “has access to all FDA-approved” tests. However, some tests must be outsourced; the BRACAnalysis, for example, must be processed by Myriad Genetic Laboratories, and the Oncotype DX assay must be processed by Genomic Health, Inc. Med fusion will be able to “carve out” those tests and handle sending out and receiving the data.

Partnering with med fusion and Foundation Medicine will “reduce variability and im-prove our approach to precision medicine,” maintains Neubauer. The US Oncology Network has the “reputation of functioning as a network,” and it is “really truly a cohesive group,” he explains to SPN. Oncologists within the network provide “high patient care, drive care and

97



are dealing with the rising costs of cancer care.” So McKesson Specialty wanted to “wrap our arms around” value-based precision medicine.

Precision Medicine vs. Personalized Medicine

This area is different from the broader “personalized medicine,” which encompasses not only a person’s genetic characteristics but also a tumor’s and informs whether one drug would work better than another. “This is too all-encompassing and doesn’t serve our pur-pose,” which is to “put a process, a plan around the fact that there are DNA alterations” that cause tumors. Understanding the characteristics of a tumor can help tailor treatment for a person, which can “have a positive impact on outcomes,” Neubauer says. “Certain targets are identified and then certain ways to attack those targets.” Precision medicine “better de-fines what we’re interested in.”

McKesson Specialty contends that the initiative will help improve care and potentially reduce the cost of care. Neubauer elaborates that “it sounds corny, but if you look at this as doing the right test at the right time, this will improve care.” In addition, “any informa-tion that can be used in an effective way can lower costs.” He points out that there is both overutilization and underutilization of molecular diagnostics. Overutilization could lead to ordering tests that aren’t really needed and won’t make a difference in treatment, while underutilization could lead to people missing out on treatments that could truly make a difference.

The program should help “reduce the unnecessary ordering of tests,” he maintains. “That’s not to say that physicians are doing the wrong thing, but this can provide guidance on when to order them” — something that Neubauer says he would have appreciated having when he was practicing. He adds that “we’re developing a very detailed education piece as part of this initiative for providers.”

The partnership stands to benefit health plans as well, contends Neubauer. “Molecular diagnostics are very expensive,” and many times, plans have “trouble seeing what they’re paying for.” For example, it wouldn’t be uncommon for a plan to receive a “nonspecific bill for $4,000.” The program hopefully should bring some clarity to this aspect of care. And “as the strategy unfolds,…there could be additional contracting opportunities to providers and health plans,” he says.

With many insurers having a network of preferred labs, usually for more basic labs, says Swick, “our hope is to have these vendors be in-network for as many payers as we can.”

According to Neubauer, “There are no financial rewards for physicians in ordering certain tests.” The collaboration is “meant to be a facilitator for them,” since determin-ing “what test to order, when and from whom” can be a “major hassle.” Ultimately, he explains, “We feel there needs to be a best-practices model in handling molecular diagnos-tics” that includes giving “guidance to physicians in the network…to help them order tests appropriately.”

Contact Neubauer and Swick through Claire Crye at [email protected]. G

98



Florida Blue and Moffitt Cancer Center Launch ACO Focused on Oncology CareReprinted from the January 2013 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

As Florida Blue continues to aggressively pursue opportunities with the accountable care organization (ACO) model, it has unveiled a second cancer-focused program. The arrange-ment with the Moffitt Cancer Center, though, is the plan’s first ACO in which it partners with a cancer-specific provider. With much of Florida Blue’s membership receiving care at Moffitt, the initiative is aiming for better integrated care, quality of care and patient outcomes — all of which should result in decreased medical costs.

The program “essentially launched Jan. 1,” says Jonathan Gavras, M.D., senior vice presi-dent, delivery system and chief medical officer for Florida Blue.

He tells SPN that it will focus on the “most common” cancers: cancers of the male and female reproductive systems, breast cancer, gastrointestinal cancers such as colon, soft tissue cancers such as lymphomas and leukemias, and respiratory/thoracic cancers such as lung. These represent 80+% of the tumors among plan members, explains Gavras.

The plan had worked with Moffitt before, and Gavras notes that the cancer center has a “stellar reputation” in not only the Tampa area but also nationally and internationally. In addition, Moffitt is one of only 41 National Cancer Institute Comprehensive Cancer Centers — and the only one based in Florida — an elite distinction that made it a desirable center with which to partner. And Moffitt “over the years has been at the forefront of health care innovation” and has been “moving toward integrated care,” so the collaboration was a “great opportunity,” contends Gavras.

“This is a win-win for both organizations as it locks in an established provider entity with Florida Blue that can keep both organizations as key players in the aged Florida mar-ket,” maintains F. Randy Vogenberg, Ph.D., a principal with the Institute for Integrated Healthcare. “For Florida Blue, it plays off of their administrative services and business con-tracting capabilities that will be more important under health reform while locking in a solid provider for an increasingly high-cost service line (cancer). For Moffitt, it immediately cre-ates continued access through the Blues beneficiaries as a preferred network that may poten-tially disadvantage all other providers for cancer care.”

As far as outcomes, the Blues plan is expecting to see “increased integration in health care, and along that line, a much tighter connection to pathways,” Gavras says. Also antici-pated are “better outcomes in care and an improvement in quality,” including a “better pa-tient experience and access to care.” When these kinds of outcomes are seen, then “you tend to see a decrease in health care costs.”

This is not the first oncology-specific ACO on which Florida Blue has collaborated. Last May, it launched a cancer-focused program with Baptist Health South Florida and Advanced Medical Specialties (SPN 6/12, p. 1). And since then, the plan has launched “full cost of care ACO arrangements,” notes Gavras. “A lot of data analysis has been put in place, and a lot of metrics have been developed.”

He explains that the arrangements with Moffitt and Baptist Health/Advanced Medical Specialties are the only disease-specific ACOs that the plan is involved in at this point. The

99



others are focused on “total cost of care.” Florida Blue also has “some bundled payment ar-rangements,” including an orthopedic arrangement with the Mayo Clinic.

But while “cancer care is a component of the care” that Baptist Health provides, Moffitt is a cancer-focused entity. “It’s what they do,” points out Gavras. With other ACOs in which the company is involved, including ones with Holy Cross Hospital in Fort Lauderdale, Baycare Health System in Tampa Bay and NCH Healthcare System in Naples, “cancer is under the umbrella” of the care provided.

“The methodologies and philosophies are pretty much the same” with the two oncology ACOs, says Gavras — improving the patient’s experience and getting the best overall out-comes. These are “quality-based initiatives.”

However, the groups involved are “two different systems. Baptist Health is a multispe-cialty system, and Moffitt is a cancer system with a very regional focus,” he explains. “A significant amount of our membership seeks care” at Moffitt, which has 330 oncology practi-tioners, Gavras adds.

The Moffitt ACO covers the Tampa Bay area, while the Baptist Health ACO is focused on Miami. “We’re not looking specifically for cancer-type ACO arrangements in other parts of the state,” he says, “but if opportunities arise,” the plan would consider them.

Asked if there were any available data on the Baptist Health ACO, Gavras notes that it is still “very, very early” in the arrangement, and that they are “just starting to look at the data now.…Complicated disease states such as oncology…are difficult programs to do” in an ACO model. But “we’re pretty encouraged” by what the plan is seeing so far.

“There will be all types and sizes of arrangements from the Blues plans like this since they want to work with all providers in both primary and specialty care arenas,” Vogenberg says. “As Blues plans move away from traditional insurance, they have to align networks with service offerings while watching their rising costs of care.”

He adds that “Commercial insurance private exchanges and other ‘retail’ insurance ef-forts as well as health purchasing groups will continue to put pressure on Blues plan pre-miums as well as provider reimbursement akin to CMS. It’s important for health plans and providers to find collaboration opportunities if either or both are to survive the implementa-tion of health care reform.”

Contact Mark Wright for Gavras at [email protected] and Vogenberg at [email protected]. G

Aetna Inks Deal With US Oncology, Will Launch Program in TexasReprinted from the June 2010 issue of AIS’s monthly newsletter Specialty Pharmacy News. Call (800) 521-4323 for more information.

After the success of a recent study, Aetna Inc. has tapped US Oncology Inc. to provide comprehensive cancer care for its members and participating oncologists.

US Oncology subsidiary Innovent Oncology will apply US Oncology’s Level I Pathways, evidence-based guidelines developed and managed by physicians within the US Oncology network. It will also provide proactive patient support services and advance care planning.

100



Aetna is the first national plan to offer the program, which launches June 1 in Texas and will serve the insurer’s fully insured commercial medical plans. According to Roy Beveridge, M.D., medical director for US Oncology, “Aetna asked to begin the program in Texas due to the large enrollment they have in the state.”

The state was also a very appropriate starting point for the Texas-based US Oncology. For one, Texas Oncology is the biggest community-based practice within the US Oncology network and has more than 300 physicians; it also “offers the largest number of physicians who have been implementing the program informally (without a payer counterpart),” says Jennifer Horspool, spokesperson for US Oncology.

Also, she says, the Texas practices have fully implemented US Oncology’s cancer-specific electronic health record, known as iKnowMed, “which provides Aetna and Innovent Oncology a better opportunity to measure the impact of the program on patients and overall cost.”

The offering should expand to other states next year, say the companies.The program will focus on the following 14 cancers, which were chosen because they are

the most commonly diagnosed, explains Horspool:(1) Breast cancer,(2) and (3) Colorectal cancer (two Pathways, one for colon and one for rectal),(4) Prostate cancer,(5), (6) and (7) Indolent non Hodgkin lymphoma (three Pathways for three disease

types),(8) Hodgkin’s lymphoma, (9) Non-small cell lung cancer (NSCLC),(10) Small cell lung cancer,(11) Ovarian cancer,(12) Multiple myeloma,(13) Pancreatic cancer and(14) Chronic lymphocytic leukemia.“These cancers are managed most often in the outpatient community-based setting, and

chemotherapy is a key treatment modality — suggesting the need for an evidence-based medicine pathway,” explains Beveridge.

Results of a study that were released in January showed that adhering to evidence-based care in the treatment of NSCLC produced an average 12-month savings of 35%. In addition, there was no difference in patient outcomes between those treated with an evidence-based guidelines approach and those treated with a nonevidence-based approach.

“We were quite successful in the study with NSCLC,” Horspool tells SPN. “Those are not necessarily the expected results for all 14 of the cancers, but we do expect to see success with all 14 cancers.”

Beveridge tells SPN that “savings vary greatly based upon the number of patients and the stage and type of cancer. Overall, we believe that similar savings are a realistic expecta-tion, but are more concerned that patients have access to evidence-based care to provide the best opportunity for survival.”

101



In other US Oncology news, the company also recently launched its Payer Quality Services offering for physicians who join the United Network of US Oncology through its Targeted Physician Services relationship.

“Payer Quality Services offers access to clinical quality benchmarking, patient and re-ferring physician satisfaction surveys and managed care contracting services,” explains Beveridge. “Some of the Innovent Oncology product components are available to physicians who purchase services through Payer Quality Services, including Level I Pathways.”

The offering will bring oncologists and payers together through pay-for-performance initiatives based on evidence-based care that will help align reimbursement, says US Oncology.

Contact Horspool at (281) 863-6739. G

102

oncology management: the aetna experience in personalized

Documents