the future of oncology reimbursement: alternate payment initiatives moderator marc samuels, jd, mha...
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The Future of Oncology Reimbursement: Alternate Payment Initiatives ModeratorMarc Samuels, JD, MHA ADVIPanelistsMichael Kolodziej, MD Aetna Kavita Patel, MD Brookings InstitutionDenise Pierce, DK Pierce & AssociatesLarry Strieff, MD Hill Physicians Robin Zon, MD Michiana Hematology Oncology; ASCO Clinical Practice Committee
The Future of Oncology Reimbursement: Alternate Payment Initiatives
Moderator Marc Samuels, JD, MPHChief Executive Officer, ADVI
What Do We Mean By Alternate Payment? Something that replaces traditional fee-for-service (FFS) That is designed to compensate for delivering a new value
proposition: “value-based” rather than “volume-based” Descriptions such as: patient-centered, coordinated,
appropriate, efficient, accessible, consistent, high-quality, affordable
Monitoring, documenting and reporting on the value Are the financial incentives aligned? Is there an assumption
of financial risk? Nothing focuses everyone’s attention like assuming financial
risk together
Various Payment Reform Options – OncologyBundling/Aggregation Across Providers
Case based physician payment
Traditional FFS
Chemotherapy Fee Replacing Drug Mark-up
Oncology ACO
Medical Oncology
Home Care Management
fee
Episode/Bundle Payment for Physician
Services
Episode/Bundle Payment Physician
and Hospital Services
Population-Based, System-Wide
Capitation Payment
Pathways Complian
ce Fee
Adapted from: Model Progression by Case-Based Physician Payment and Bundling/Aggregation across Providers. Source: The Brookings Institution, 2013.
Shar
ed S
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gs
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ed S
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Key Features of Three Major InitiativesCMMI-OCM CAP Consortium ASCO-CPOC
Aligned financial incentives to improve care coordination, outcomes, access, higher quality at lower cost (“triple aim”)
Re-align financial incentives to influence efficiencies, appropriate use (not under/not over use), quality consistency
Enable high-quality, patient centered care and more affordable cost; reduced administrative burden [on practice]
Patients undergoing chemotherapy, all cancers
Begin with high prevalence cancers (metastatic NSCLC, colon)
All cancers
Multi-payer Multi-payer Multi-payer
PBPM care management payment plus shared savings on total cost of care. Transition to 2-sided risk
Bundled payment for total cost of care (drug cost carved out)
5 types of bundled payments. Administrative efficiency: reduce from 58 CPTs to 11 service codes
“Practice Requirements” for monitoring, reporting
Standard set of quality measures – all payers
Value measures: pathways adherence, QOPI, ER frequency
The Future of Oncology Reimbursement: Alternate Payment Initiatives
Kavita Patel, M.D., MSManaging Director for Clinical Transformation & Delivery Engelberg Center for Health Care Reform Studies, Brookings Institution
© The Brookings Institution. All rights reserved. No part of this presentation may be reproduced or transmitted in any form or by any means without permission in writing from the Brookings Institution, 1775 Massachusetts Avenue, N.W., Washington, D.C. 20036 (Email: [email protected]).
Kavita K. Patel MD, MSFellow and Managing Director
Brookings Institution
The Future of Oncology Reimbursement: Alternate Payment Initiatives
Michael Kolodziej, M.D. National Medical Director Oncology Solutions, Aetna
• We give our members access to high-value, personalized cancer care models. We collaborate with oncology teams that deliver best-in-class care by using evidence-based medical guidelines, clinical decision support tools and services that improve the patient’s experience, increase effectiveness of care and lower costs. Our value-based approach, powered by data analytics and transparency of policy and payment, allows us to move from a fee-for-service platform to a value-driven system that rewards Oncology practices for quality care throughout the patient’s care journey.
Aetna Oncology Solutions – Mission Statement:
Aetna Values & Oncology Solutions Mission Statement
Six realities that will shape reimbursement reform for commercial payers
Employers pay the bills Profitability depends on private payers Transparency will become mandatory Innovation is expensive Hospitals (in their current iteration) are immune to reform
… and that must change Cancer costs involve more than just the drug
Buchmueller et al.Health Affairs 32: 1522-30
Aggregate Hospital Payment-to-cost Ratios
Distribution of Hospital Cost by Payer Type (% of Total Cost) - 1980 / 1990 / 2010
Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2010
Aetna’s Oncology Solutions
Aetna’s Oncology Solutions
• 172 clinics closed
• 323 practices struggling financially
• 44 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
16
Cancer is the most costly medical item and increasing at 2-3x the rate of other costs
1996 20100%
1000%$55 B
$123 B
Cumulative percentage increase
*2010 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC
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
Historical payer responses: why we need a novel solution
• 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)
18
Oncology reimbursement reform
MUSTReduce costImprove qualityBoth
• Evidence based medicine
• Enhanced access• Shared decision
making• Coordination of care• Quality reporting• Payment reform
22
Quality reporting: clinical process measures
1. Adherence to evidence based treatment guidelines (including treatment exceeding lines of therapy and documentation of off-pathways reasons)
2. Cancer staging3. Performance status4. Pain assessment5. End of life metrics (ACP documentation, hospice
enrollment, hospice length of stay)6. Patient satisfaction
23
Quality reporting: financial measures
1. ER visits (and costs)2. Hospitalization rate (and costs)3. Chemotherapy costs
• NOTE: These measures form the basis for the shared savings calculation
24
ER and Hospital: Index PracticeER IP IP LOS
Breast (n=52) 29 24 3.7
Colon (n=14) 14 21 8
Lung (n=24) 18 31 5.4
Total 61 76 5.6
Chemotherapy costs
N ME CP
Breast 52 28325 25307
Colon 14 28819 38616
Lung 24 19576 17892
Fewer cancer related ER visits and in-patient
admissions
Fewer cancer-related in-patient hospital
days
Greater adherence to Pathways regimen
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
27
Reimbursement Models
1. Implementation fee2. Management fee3. Enhanced fee schedule4. S codes5. Shared savings6. Prior auth relief
• Treatment plan• End of treatment summary• Advanced care plan• Oral chemotherapy management fee
Aetna Oncology Medical Home payment for oncology care means growth instead of shortfall
Sustainable Future
Performance
*Ultimately, this becomes
a better “reset”
baseline for episodes
and/or bundles
Current Fee for Service Model Invest in
New processes
Shared Savings on
improvement from
baseline outcomes
Enhanced drug fee schedule
Changes in pre-cert
model alter FTE’s
S-codes for quality
processes that have meaningHIT Office
workflow efficiencies
Our goal is to create a sustainable business model designed around new sources of value that will be resilient through and post health care reform.
Growth
Future Base
Model(s) Without Medical
Home-like contracts
Revenue Gap(e.g., private payer and
CMS induced)
So how does this apply to MCR?
MCR is the dominant payer for virtually every oncology practice
Cancer is far more common in the MCR population Cancer is more expensive in the MCR population MCR cancer patients are different in many ways In general, MCR doesn’t pay very well MCR rewards volume not quality SO MCR needs to change
So what about the CMMI proposal ?
Rewards practices for enhanced clinical services and performance
Determining management fee is problematic Gain share methodology unclear Too directive Too many data elements to report Will be most successful if commercial payers participate BUT it is generally consistent with our view of
reimbursement reform (so we are exploring ways to partner with CMMI)
Oncology reimbursement reform is a step-wise process
Vendor based programs introduce Clinical Pathways and Measure Adherence along with Quality Measures
More sophisticated Practices move from vendor based Clinical Pathways programs to Oncology Medical Homes (OMH)
Smaller Practices work with Education Oncology programs such as NJ ION program
Create episode and bundling methodology test with OMH, as well as deployed in ACO
Provider engagement Index
Low Touch High Touch
Some Clinical Engagement
OMH deployed in 65% of markets and ACOs by 4Q15
More Clinical Engagement
High Clinical Engagement
The Future of Oncology Reimbursement: Alternate Payment Initiatives
Robin Zon, M.D., FACP, FASCOMichiana Hematology Oncology, Chair ASCO Clinical Practice Committee
Consolidated Payments for Oncology Care
Payment Reform to SupportPatient-Centered Care for Cancer
ASCO’s Clinical Practice Committee Payment Reform Work Group
(JOP Jul 1, 2014:254-258; published online on April 15, 2014)
Goals of CPOC Payment structure
Patient centered Better match to services we
provide/patients need
Simpler billing structure
More predictable revenue stream
Incentivize high quality, high-value care
Support coordinated, patient-centered care
Components of CPOC
• The Quality Oncology Practice Initiative
• A Chemotherapy Management Fee
• Value Based Pathways
• Monthly Episodes of Care/Bundled Payments
• Care coordination/ Patient – centered Medical Oncology Home
Monthly PaymentsBased on Phases of Care
New Patient Payment
Single payment
Includes patient evaluation, treatment planning, patient education
Diagnostic testing paid separately
Treatment Month PaymentSingle payment each month patient receives treatment (IV or oral therapy)
May receive both a treatment month payment and a new patient payment in the same month
Higher monthly payments for sicker patients and those receiving more toxic and complex regimens
Monitoring Month Payment
• For patients not receiving active anti-cancer therapy (e.g. treatment holiday or completion)
• 3 levels of payment₋ Higher for months immediately following end
of treatment₋ Lower for patients on long-term monitoring
Transition of Treatment Payment
Patient beginning new line of therapy or ending treatment with no further treatment planned
Reflects time involved in treatment planning and patient education
Continued FFS Payments
Laboratory tests
Bone marrow biopsies
Portable pumps
Blood transfusions
(list not all inclusive)
Additional Payment Adjustments
Quality measures phased in over time
Pathways, two stages: Adherence Use of certified pathways
Resource utilization OMH ER and hospital admissions
Clinical Trials Higher Treatment Month and
Non-Treatment Month payments for enrolled patients
Multi-Year Transition Design
Net revenue to practice > existing system
Total spending by payer < existing system
Payer and practice negotiate acceptable risk corridors during transition Practices protected against losses in initial years Payers and practices share in savings achieved Practices take on greater accountability as care
processes redesigned
ASCO’s Efforts to Lower Costs, Increase Value
Promoting Adherence to Evidence-Based Medicine: ASCO Guidelines
Participating in & Promoting “Choosing Wisely”
Commitment to Quality Improvement: QOPI
Working with Payers: Integration of Quality Measures into Reimbursement Decision-Making
Cultivating a Learning Healthcare System: CancerLinQ
Establishing Clinically Meaningful Outcomes in Cancer Research
Payment Reform
The Value in Cancer Care Task Force
CMMI vs. CPOC: Some Observations
CMMI: OCM
Fee for service—current narrow categories
Reimbursement still driven by physician encounter
Add on payment only for new services
Accountability for ALL healthcare services
Arbitrary 6-month episodes
Payment differentiated only by type of cancer
ASCO: CPOC
Flexible payments can reimburse currently unfunded services
Patient centered reimbursement, agnostic to type of provider
Monthly payment replaces current fees
Focuses accountability on services controlled by oncologists
Monthly payment based on phase of treatment and care
Payment differentiated by patient complexity and treatment toxicity
DISCUSSION
The Future of Oncology Reimbursement: Alternate Payment Initiatives
Larry Strieff, M.D.Specialty Medical DirectorHematology Oncology Division ChiefHill Physicians Medical Group
Oncology Case Rate (OCR)Payment Reform Example
Larry Strieff, MD, Specialty Medical Director, Hematology Oncology Division Chief
Clinical Support, Hill Physicians Medical Group
Hill Physicians Medical GroupIndependent Physician Association founded in 1984Provider network: 3,800 providers and consultants
980 Primary Care 2,260 Specialists (170 Oncologists)
Service the Northern California area 300,000 Members 5 Regions - 9 Counties
51
Methodologies Evaluated52
Mutually Sustainable
Mutually SustainableFFSFFS
FFS & Cap
FFS & Cap
Flat Cap Rate
Flat Cap Rate
Drop to MC RatesDrop to
MC Rates Aligned Incentives*Cost
*Quality*Patient Experience
Aligned Incentives*Cost
*Quality*Patient Experience
Cohort Case Rate
Cohort Case Rate
Chronological Cost Pattern for Breast Cancer
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35
Paid
per
Cas
e
Months Following Initial Diagnosis
Other Radiology
Radiation Oncology
Medical Oncology
53
Oncology Case Rate (OCR)Bundled Payment System
54
OCR Cancer Cohorts:Diagnosis Group by Cancer Type
55
Cohort
Cancer TypeTotal Unique
Patients, 2010-2014 YTD
1 Colon & Rectum 116
2 Lung 136
3 Breast (female) 287
4 Ovary and other Uterine Adnexa 23
5 Prostate 41
6 Malignant Neoplasm of Other/Unspecified Sites 50
7 Malignant Neoplasm of Lymp/Hema Tissue 169
8 Other Malignant Neoplasm 158
9 Diseases of Blood & Blood-Forming Origin 27
Total Unique Patients 1,007
56Trends in Oncology PMPM Network vs. Sacramento OCR
Quality Management Bonus ProgramProgram encompasses 3 domainsClinical measures are subject to audit and chart reviewsPerformance dashboards are shared with oncology groups
regularly
57
Clinical Quality of Care58
OCR PerformanceASCO = American Society of Clinical Oncology
59
Utilization Measure60
Inpatient Bed Days
Overall Survival Results61
OCR (N=128) vs. Control (N=146)p = 0.05
All 4 Cancer Cohorts (N=274){Esophageal, Pancreas, Lung, Stomach}
Survival Time (days)Day 0 = first day of chemotherapy
Su
rviv
al P
rob
ab
ilit
y
Summary OCR practices demonstrated year-over-year
improvements in performance on ASCO clinical quality measures.
OCR practices out-performed standard FFS model in satisfaction and utilization metrics year-over-year.
OCR practices’ overall survival is non-inferior to the overall survival under a standard FFS model.
OCR practices continue to bend the cost curve over 3.5 years of program experience.
62
The Future of Oncology Reimbursement: Alternate Payment Methodologies – Employer Perspectives
Denise K. PiercePresident/CEODK Pierce & Associates, Inc.www.dkpierce.net
An Employer’s View on Cancer Costs
64
Employees with cancer result in more than 33 million disability days per year.1
Employees with cancer result in more than 33 million disability days per year.1
Of the 12 million Americans with cancer today, an estimated 3 million are actively employed.2
Of the 12 million Americans with cancer today, an estimated 3 million are actively employed.2
Since employer’s cancer medical expenses are increasing faster than general medical costs, there is no waiting for payment reform – employers are increasingly taking direct action to manage cancer costs now
Sources:1.“Cancer Costs Billions Yearly in U.S.” US News and World Report. December 2012.2.Miller, S. “Employers Focus on Cancer Prevention and Care.” Society for Human Resource Management. November 20133.Herr, J. “Employers Becoming More Savvy About Specialty Pharmacy, but Need More Cost Controls.” Midwest Business Group on Health. February 2013.
Specialty oncology drugs currently account for approximately 17% of the average employer’s total pharmacy spend and are estimated to rise to 40% by 2020.3
Specialty oncology drugs currently account for approximately 17% of the average employer’s total pharmacy spend and are estimated to rise to 40% by 2020.3
Employer Approaches to Managing Cancer Costs
Employer Initiatives
There is a wide variation in approaches, based on company industry, size, and employee demographics
Claims data warehousing/analysis
Specialty pharmacy benefit
Nurse navigators
Value-based payment design
Oncology medical homes
Solid tumor mapping
• Overall cancer costs/targeting• “per employee” costs for benefit forecasting
• Case managing the “right treatment for the right patient”• Integrating adherence measures
• Care coordination beyond the practice doors• Drug/treatment adherence
• Oncology pathway integration• Natural narrower networks based on participation
• Learning from current primary care models
• Individualized treatment decision support
Source: DK Pierce & Associates, Inc. DKP Critical Insights®: Employer Cancer Management Evolution Analysis 2014.
Employer Example – Centers of Excellence
Shell Oil Cancer Center of Excellence (COE)
• Voluntary program contracted through MD Anderson• Applies to active employees and non-Medicare pension retirees• Registered employees and adult dependents would have prevention and
treatment with no deductibles, no coinsurance• Services directed to MD Anderson main campus
EmployeeEmployee
Voluntary Program Registration
MD Anderson Physician
Network Case Manager
MD Anderson Physician
Network Case Manager
• Prevention screening• Adult cancer treatment
Employees with pre-existing cancer conditions will be managed through the ASO United Healthcare network, with applicable deductible and cost share
Business Coalition Roles in Managing Cancer Costs
Business Coalition Initiatives
• Cancer benefit guidanceo National Business Group on Health (NBGH) Cancer Benefits Resource Guide program
resourceso National Business Coalition on Health (NBCH) Action Briefs
• Specialty pharmacy model contracts• Setting of care analysis• Claims data evaluation support
Once serving only as leverage for insurance purchasing, business coalitions now take on key roles to guide benefit design
Sources:DK Pierce & Associates, Inc. DKP Critical Insights®: Employer Cancer Management Evolution Analysis 2014. National Business Group on Health An Employer Guide to Cancer Treatment and Prevention. Tool 2- Plan Design and Assessment http://www.businessgrouphealth.org/pub/f3128ebd-2354-d714-5131-878172bcc648National Business Coalition on Health. http://www.nbch.org/
Business Coalition Roles in Managing Cancer Costs
Sources:National Business Coalition on Health. NBCH Action Brief. Breast Cancer – Take Action. http://www.nbch.org/nbch/files/ccLibraryFiles/Filename/000000003417/NBCH_BREAST%20CANCER_FNL.pdfNational Business Group on Health An Employer Guide to Cancer Treatment and Prevention. Cancer Continuum of Care. http://www.businessgrouphealth.org/cancer/index.cfmMidwest Business Group on Health. National Employer Initiative on Specialty Pharmacy. http://www.specialtyrxtoolkit.com/
Business Coalition Roles in Managing Cancer Costs
NBGH COE criteria are supplied in the Employer’s Guide to Cancer Treatment & Prevention
National Business Group on Health An Employer Guide to Cancer Treatment and Prevention. Centers of Excellence Network Programs. https://www.businessgrouphealth.org/pub/f3131588-2354-d714-5137-54d58bc3882d
Denise K PiercePresident/CEODK Pierce & Associates, [email protected] ext. 205