Oncology Management at HAP. John Calabria, DO, Medical Director

Transcription

1 Oncology Management at HAP John Calabria, DO, Medical Director

2 Agenda Rising Cost of Health Care Ways of Managing Oncology Cost Pathways Update Where do we go from here?

3 The Cost of Cancer Source: National Cancer Institute

4 What is the best reimbursement model? Fee for Service Enhanced Fee-for-Service Bundled Payments Shared Savings Shared Risk Full Capitation

5 Ways Oncology Cost can be Managed Prior-Authorization Payment Reform Aggressive Pharmacy Benefit Management Specialty Pharmacy Care Management (informed decision-making) Alignment of Incentives Retail Infusion Centers Radiation Oncology Management Benefit Management Collaborative Payer/Physician Programs Front-End/Back-end Compliance Programs

6 Pathways (through Cardinal Health) Prior authorizations are NOT required Fee schedule payments to physicians are NOT reduced A steering committee is formed and oncologists develop their preferred pathways Pathway selection is based first on efficacy, then toxicity and finally costs Oncologists agree to use these pathways and their compliance is tracked (breast, lung, & colon)

7 Why Participate with HAP Pathways Initiative? Enhanced reimbursement for generic drugs (brand drugs remain available) Opportunity for a collaborative relationship Already doing it for other payers Physician still has ultimate control of treatment at point of care

8 How Pathways Reduce Cost Reduce variation (including off-label) Convert from brand to generic regimens Decrease lines of therapy when there is no supporting evidence Appropriate use of biologics Decrease avoidable acute care Timely referral to clinical trials and end-of-life care

9 Recruitment Summary

10 Timeline

11 Outcomes First compliance report after March 2013 Demonstration of savings later in 2013

12 What else are we doing that impacts oncology? Utilization management of select oral agents by HAP s pharmacy department Utilization management of oral oncology agents by contracted specialty provider Imaging management Genetic testing management Cancer screening interventions

13 What else are we doing that impacts oncology? (cont.) Promoting personalized medicine (e.g., KRAS) when evidence-based Evidence-based benefit design Case management HAP In-Home Care Program Radiation therapy management

14 Where do we go from here? Fee for Service medicine is being challenged on all fronts CMS (Medicare and Medicaid) Pioneer ACO pilots Bundled payment pilots CMMI Grants Health Plans (Commercial, Medicare Advantage & Medicaid) Employers are experimenting with similar models Between now and 2020 it is expected there will be a major shift to a risk based reimbursement method Payer and provider organizations will need to coordinate a shift in population risk management infrastructure from payers to providers.

15 Things that organized providers will need to do Panel management Quality management Inpatient hospital utilization Outpatient hospital utilization Physician utilization Lab utilization Radiology utilization Information management

16 Preparing practices for alternative payments models (CMS will likely launch oncology bundling by 2016) Pilot programs (ideally with some level of risk) Data sharing (performance metrics) Evidenced-based use of new technology Care Management (informed decision-making) Promoting evidence-based treatment protocols Working with our Physician Organizations Collaboration and transparency Building relationships and trust Remaining open-minded to other approaches

17 Adapted from: Bending the Cost Curve in Cancer Care Thomas J. Smith, M.D., and Bruce E. Hillner, M.D. NEJM: May 26, Selective testing and imaging 2. Appropriate second-line and third-line treatments 3. Chemotherapy to patients with good performance status 4. Appropriate use of white cell stimulating factors 5. Timely access to clinical trials 6. Understanding the cost drivers 7. Realistic expectation 8. Realign compensation 9. Better Integration of palliative care 10. Importance of driving high value

18 John Calabria, DO