How health plans can improve cancer care: from utilization management to delivery reform

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1 Quality health plans & benefits Healthier living Financial well being Intelligent solutions How health plans can improve cancer care: from utilization management to delivery reform Michael Kolodziej, M.D., FACP National Medical Director, Oncology Solutions Aetna Aetna Values & Oncology Solutions Mission Statement Aetna Oncology Solutions Mission Statement: 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 s Oncology Solutions Aetna Inc. 1

2 Outline Why does oncology need a solution? Evidence based treatment as a solution The oncology medical home as a better solution Aetna as solution provider Cancer is the most costly medical item and increasing at 2 3x the rate of other costs Cancer care is the leading edge of medical cost trend 1000% 0% Cumulative percentage increase $55 B $123 B Annual Increase Cancer Drugs 20% Cancer Medical 12 18% Health Care 9% US GDP 3% Aetna's top cost drivers in cancer care Medical Rx 30.8% $1.5B Inpatient 23.3% $1.1B Radiology 22.4% $1.1B Specialist Physician 9.4% $483M *2010 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC Aetna s Oncology Solutions 2

3 Aetna s Oncology Solutions Death rates from cancer are decreasing but the decline is small compared to heart disease. From Jemal, A. et al. Death Rates for Cancer and Heart Disease for Ages Younger than 85 Years and 85 Years and Older, CA Cancer J Clin 2009;59: Aetna s Oncology Solutions 3

4 The Health Care System Produces $750 Billion in Yearly Waste Prevention failures Unnecessary services Excess administrative costs 7% 27% 10% U.S. health care 14% system waste 25% 17% Fraud Inflated prices Inefficient care delivery ~30% of health spending is waste Source: Institute of Medicine; 2009 data 7 Aetna s Oncology Solutions 4

5 Health Care Premiums are Growing at 3x the Rate of Inflation and Wages Cumulative increases from % Health insurance premiums 47% Workers earnings 38% Overall inflation Source: Kaiser/HRET Survey of Employer Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index and Employment Statistics Survey Aetna s Oncology Solutions Consumers are Paying for Half the Increase in Medical Premiums Consumer Employer Source: Kaiser/HRET Survey of Employer Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index and Employment Statistics Survey COST SHARE P COST INCREASE $6,228 48% (contributions + out of pocket) 52% $2,989 $3,239 5

6 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) 11 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 A differentiated strategy for cancer care 2012 Aetna Inc. 12 6

7 Increased adherence to evidence based guidelines lowers cost without negatively impacting treatment efficacy 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 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. Significantly lowered cost in the case group vs. The control group 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 Volume 6. No.1. p Overall survival by Pathway status. A differentiated strategy for cancer care Aetna s Oncology Solutions 2012 Aetna Inc

8 Results on Evidence Based Medicine Adherence Pre Pilot Baseline Adherence For every 100 patients treated in 6 oncology practices in the 6 months prior to using the clinical decision support system, 62 received an evidenced based treatment plan Pilot Group Adherence For every 100 patients treated in 6 oncology practices when using the clinical decision support system during the pilot, 87 received an evidenced based treatment plan Patient receiving an evidence based treatment plan Patient receiving a non evidence based treatment plan Our study showed a 43% relative improvement in adherence to evidence based treatment selection Peer reviewed, published evidence based treatment options, sourced from leading oncology guideline bodies such as the American Society of Clinical Oncology and the National Comprehensive Cancer Network, were selected for 25 more patients for every 100 cancer patients in our study 15 Adherence to Evidence Based Medicine by Cancer Type Results Exceeding our Expectations Across the board, our hypothesis was confirmed relative to increased adherence to EBM Baseline adherence data on more than 200 patients was pulled from chart review of 5 practices for the 6 month period prior to the start of our pilot We compared our study group of 103 patients against this baseline data, examining changes in evidence based adherence in total, the absolute increase was 25%, a 43% relative increase Pre /Post Study Comparison in Adherence to Evidence Based Medicine 100% 75% 50% 62% 87% 79% 79% 69% 91% 79% 89% 61% 100% 51% 89% Baseline Study 25% 0% 0% Total Colorectal Breast Lung Lymphoma Other Study Sample Size

9 Pathways require Evidentiary and operational process Measurement and reporting Pathways are derived from a focus on high quality, cost effective regimens Eligible for Instant Authorization Eligible for Instant Authorization Eligible for Instant Authorization Eligible for Instant Authorization Eligible for: Instant Authorization Quality Performance Plan 18 9

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11 21 Enabling physicians with clinical decision support tools helps improve care, reduce costs and maintain quality Aetna oncology pilot study with 156 physicians in 7 locations Net savings of $393,599 included in reduced ER visits, inpatient hospital stays and spend on certain drugs Treatment variability 28 % reduced 11 % Regimen increase of generic only utilization 22 11

12 Clinical Decision Support Options

13 25 What are the PCMH joint principles? Personal physician o o o Each patient has an ongoing relationship with a personal physician Personal physician leads a team of individuals that takes responsibility for the ongoing care of patients 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 26 13

14 Expected benefits to health care consumers 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

15 How does this apply to oncology? Evidence based medicine Enhanced access Shared decision making Coordination of care Quality reporting Payment reform ER Utilization of Chemotherapy Patients Milliman Analysis of Medstat 2007, 14 million commercially insured lives, 104,473 cancer patients, Milliman Health Cost Guidelines 2009, Fitch K, Iwasaki K, Pyenson B. Cancer Patients Receiving Chemotherapy: Opportunities for Better Management. March 30 th, 2010, Milliman 30 15

16 Inpatient Utilization of Chemotherapy Patients Milliman Analysis of Medstat 2007, 14 million commercially insured lives, 104,473 cancer patients, Milliman Health Cost Guidelines 2009, Fitch K, Iwasaki K, Pyenson B. Cancer Patients Receiving Chemotherapy: Opportunities for Better Management. March 30 th, 2010, Milliman 31 ER visits per chemotherapy patient have dropped by 70 percent since 2005 Source: Dr. John Sprandio. Reused with permission. Do not distribute

17 Hospital admits per chemotherapy patient have dropped by 50 percent since 2007 Source: Dr. John Sprandio. Reused with permission. Do not distribute. 33 How do you accomplish this? Triage reform Patient education?extended office hours 17

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19 Via Oncology Pathways Treatment Summary Auto generated at end of Tx State/stage of disease Actual treatment delivered Can be edited, printed and saved within Pathways Pre populated with Survivorship Pathways (incl. Surveillance Plan) Ability to display: Response, Reason for Stopping Actual toxicities and hospitalizations Customizable by practice 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 staging 3. Performance status 4. Pain assessment 5. End of life metrics (ACP documentation, hospice enrollment, hospice length of stay) 6. Patient satisfaction 38 19

20 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

21 ER and Hospital: Index Practice ER IP IP LOS Breast (n=52) Colon (n=14) Lung (n=24) Total Chemotherapy costs N ME CP Breast Colon Lung Effective patient management programs streamline care delivery and reduce costs 80% 60% 40% 20% 0% Greater adherence to Pathways regimen 76% Patients enrolled in Innovent program 63% Control group Onpathways Fewer cancer related ER visits and in patient admissions 30% 25% 20% 15% 10% 5% 0% 10% 18% ER visits 14% 24% In patient admissions Patients enrolled in Innovent program Control group Fewer cancer related inpatient hospital days Control group Innovent 1.2 Avg. inpatient hosptial days 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 A differentiated strategy for cancer care 2012 Aetna Inc

22 Reimbursement Models 1. Implementation fee 2. Management fee 3. Enhanced fee schedule 4. S codes 5. Shared savings 6. Prior auth relief 43 S codes Treatment plan End of treatment summary Advanced care plan Oral chemotherapy management fee 22

23 Aetna Oncology Medical Home payment for oncology care means growth instead of shortfall Growth Current Fee for Service Model Revenue Gap (e.g., private payer and CMS induced) Future Base Model(s) Without Medical Home like contracts Invest in New processes Changes in pre cert model alter FTE s HIT Office workflow efficiencies Enhanced drug fee schedule S codes for quality processes that have meaning Shared Savings on improvement from baseline outcomes Sustainable Future Performance *Ultimately, this becomes a better reset baseline for episodes and/or bundles 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. *Diagram is illustrative and for discussion purposes only Aetna Inc. The typical oncology practice has challenges 1. Average number of physicians=5 2. About 60% 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. A differentiated strategy for cancer care 2012 Aetna Inc

24 A differentiated strategy for cancer care 2012 Aetna Inc. The Virtual Nurse Navigator in Action Patient receives positive diagnosis Patient sees oncologist to verify diagnosis and select treatment Virtual nurse navigator provides initial education to engage patient and family Treatment begins with 1 st round of chemotherapy Virtual nurse navigator reviews tolerance to therapy and counsels patient on toxicity management Treatment Treatment Treatment Patient receives final cycle of chemotherapy 1. Patient identification and initial outreach with focus on education. 2. Ongoing evaluation of symptom and toxicity burden. 3. Management focused on optimal patient outcome Virtual nurse navigator completes end of treatment summary 48 24

25 A differentiated strategy for cancer care 2012 Aetna Inc. 49 As community oncologists migrate to hospital systems, cost increases 172 clinics closed 323 practices struggling financially 44 practices sending ALL patients elsewhere for treatment 224 practices acquired by a hospital Source: COA Practice Impact Tracking Database 102 practices merged/acquired 50 25

26 A differentiated strategy for cancer care 2012 Aetna Inc. 51 Hospital providers need a new business model for financial sustainability Aggregate Hospital Payment to cost Ratios Breakeven Private payers are Hospitals most profitable business Distribution of Hospital Cost by Payer Type (% of Total Cost) 1980 / 1990 / 2010 And they are a shrinking part of Hospital revenues Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2010 A differentiated strategy for cancer care 2012 Aetna Inc

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28 The 5 Step Oncology Care Delivery Process Aetna Facing ACO Facing Design High Value Programs Rigorous Measurement Across Individual ACO s and BoB Drives Future Program Design 1 Modeling 2 Clinical Analytics 3 Value Creation Plan $$ ACO Current Medical Costs pmpm Potential Savings Benchmark 5 Ongoing Collaboration Measure Refine Measure A differentiated strategy for cancer care $ Potential Savings 4 Delivery Aetna Practice MCC Value IP admits $$$ ALOS $ ED $ EBM $$ adherence ChemoTx $$ Radiology $$ Rad. Onc. $$$ Lab $ Self Mgmt. $ EOL $ Discussion Hospice $$ days %death in $ hospital Project Implementation Plan Data Personnel Workflow MCC 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 CDS tool use Guidance on network partners for ancillary and adjunctive services, and expanded CM services Negotiate Targets Actual $ 50% to practice Savings Shared $ 50% to Aetna* $ Capability Aetna Typical ACO Data Warehouse Technology stack Platform Care Management Risk Stratification / Identification Member Engagement Electronic Medical Record Real Time Management Population Management Reporting 2012 Aetna Inc. 55 A differentiated strategy for cancer care 2012 Aetna Inc. 28

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30 Oncology reimbursement reform is a step wise process Vendor based programs introduce Clinical Pathways and Measure Adherence along with Quality Measures Smaller Practices work with Education Oncology programs such as NJ ION program More sophisticated Practices move from vendor based Clinical Pathways programs to Oncology Medical Homes (OMH) Create episode and bundling methodology test with OMH, as well as deployed in ACO OMH deployed in 65% of markets and ACOs by 4Q15 Vendor Oncology Programs Cardinal, New Century Health, Innovent Low Touch Some Clinical Engagement Oncology Medical Homes Provider engagement Index More Clinical Engagement Bundles/ Episode Payments OMH, ACOs, Bundles High Touch High Clinical Engagement A differentiated strategy for cancer care 2012 Aetna Inc

31 OCMO Oncology Solutions Team Geli Ira Maria Amy Mike OMH