Quantifying Physician Performance Defining the Value Equation Lalan S. Wilfong, M.D. Medical Director Quality Programs and Value Based Care Texas

Quantifying Physician Performance Defining the Value Equation Lalan S. Wilfong, M.D. Medical Director Quality Programs and Value Based Care Texas Oncology, PA

What s the Goal? Improve patient care Meet metrics for contract performance 24/7 patient access Navigation EHR use Treatment consistent with national guidelines Treatment plan completion Documentation completion Reduce costs

How to Define Measures Physician Driven Measurable Benchmarks Reportable Process improvement Accountable 3

Texas Oncology Strategy for Managing Value Based Contracts Quality improvement Hospitalization and ER visit control End of life care/advance care planning to improve hospice utilization Quality metrics Cost decrease Pathways Growth factor utilization Shared decision making 4

Texas Oncology Strategy for Managing Value Based Contracts Quality improvement Hospitalization and ER visit control End of life care/advance care planning to improve hospice utilization Quality metrics Cost decrease Pathways Growth factor utilization Shared decision making 5

Level I Pathways, Value Pathways powered by NCCN and Clear Value Plus

Level I Pathways (original mission statement) The mission of The US Oncology Network s Pathways program is to deliver the highest quality and highest value cancer care to patients through a physician-driven, Network-supported program utilizing evidence-based medicine

Level I Pathways Development Key Guiding Principles Review the evidence: science comes first Based on the strongest available data for efficacy, balanced with toxicity 80/20 Rule: Recommend therapies that work for the majority of patients and clinical scenarios Find the balance point: Maximize patient benefit and accountability for healthcare expenditures Always make clinical trials the first choice for On-Pathway Limit lines of therapy when data does not show benefit for treatment continuation Pathways are reviewed on quarterly basis Participating oncologists are encouraged to provide feedback 8

Cost and quality value of Level I Pathways demonstrated in two different studies MHSC 2012 9

Level I Pathways Equivalent Health Outcomes Overall Survival by Pathways Status 1 Overall Survival Probability 0.8 0.6 0.4 0.2 0 On-Pathway (n=1,095) Off-Pathway (n=314) 3 mos 6 mos 9 mos 12 mos SOURCE: * Neubauer, et al., Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non Small Cell Lung Cancer in the Community Setting. JOP 2010;6:1 10

Value Pathways powered by NCCN Physician-led clinical pathways NCCN Guidelines Co-developed with NCCN Value Pathways powered by NCCN 11

The Texas Oncology Model Use pathways performance as the foundation for performance payment Applies to Medical Oncologists and Hematologists Put 50% of productivity bonus at risk (approximately 2-3% of total compensation) Pathways compliance 75% or greater 100% of bonus 65-74% 75% of bonus 64% or less 50% of bonus 12

The Texas Oncology Model Data will be scrubbed and physicians can make corrections and appeals Adjustment will be made for new regimens Individual physician circumstances will be addressed Off pathway exceptions Initially reviewed by a regional medical director with approval based on data, efficacy, cost, toxicities and inclusion on NCCN guidelines Exception committee involvement when regional medical director declines yet physician wants to pursue treatment 13

CVP decision support example 14

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Tools for managing pathways 16

Tools for managing pathways 17

Reporting Compliance trend (NCCN Guidelines) filtered by provider NOTE: Demo data does not imply actual compliance results

Process - Impact of compensation on pathways compliance Pathway Compliance All TxO April 2013 (pre-bonus) vs. April 2014 (post-bonus) 90% 85% Average 83% 80% 75% 70% Average 78% J J A S O N D J F M A M J J A S O N D J F M A

Technology - Impact of CVP on pathways compliance 100% Pathway Compliance - September 2014 (pre-cvp) vs. September 2015 (CVP) 86% 91% 81% 89% 91% 90% 89% 89% 79% 78% 83% 90% 50% 0% CTR GCR NTR WTR WTRM ALL TxO 2014-Sept (pre CVP) 2015-Sept (CVP)

GCSF Utilization in Metastatic Disease Physician Met Pts GCSF used % GCSF used Mickey Mouse, MD 21 1 5% Homer Simpson, MD 17 3 18% Princess Leah, MD 14 7 50% Jon Snow, MD 11 5 45% Sheldon Cooper, MD 8 2 25% Al Bundy, MD 8 4 50% Katniss Everdeen, MD 7 0 0% Rick Grimes, MD 7 1 14% James Bond, MD 6 4 67% Charlie Brown, MD 6 1 17% 21

GCSF Utilization in Metastatic Disease Physician Met Pts GCSF used % GCSF used Mickey Mouse, MD 21 1 5% Homer Simpson, MD 17 3 18% Princess Leah, MD 14 7 50% Jon Snow, MD 11 5 45% Sheldon Cooper, MD 8 2 25% Al Bundy, MD 8 4 50% Katniss Everdeen, MD 7 0 0% Rick Grimes, MD 7 1 14% James Bond, MD 6 4 67% Charlie Brown, MD 6 1 17% 22

Texas Oncology Strategy for Managing Value Based Contracts Quality improvement Hospitalization and ER visit control End of life care/advance care planning to improve hospice utilization Quality metrics Cost decrease Pathways Growth factor utilization Shared decision making 23

OCM Data OCM - 1 (unadjusted) % of Episodes w/ Admit OCM - 2 (unadjusted) OCM-3 % Admitted to Hospice 3+ Days % P ts w/ Chemo Last 14 Days % P ts Who Died in Hospital Site % of Epis odes w/ ER Visit or Observation Stay Practice 1 33.6% 27.9% 52.2% 12.5% 17.4% Practice 2 26.0% 21.3% 57.1% 14.9% 14.3% Practice 3 32.6% 21.6% 27.3% 27.3% 31.8% Practice 4 36.3% 27.1% 49.2% 20.3% 25.4% Practice 5 28.7% 20.6% 66.7% 9.3% 13.9% Practice 6 27.8% 24.6% 60.6% 13.0 % 18.6% Practice 7 32.4% 25.4% 54.3% 12.9% 18.6% Practice 8 33.9% 23.9% 55.2% 12.6% 20.2% Practice 9 28.0% 19.7% 56.6% 9.4% 17.0 % Practice 10 57.1% 32.7% 52.2% 13.0 % 32.6% Practice 11 35.9% 25.5% 57.1% 13.2% 24.9% Practice 12 25.5% 19.4% 53.4% 14.5% 22.1% Practice 13 28.8% 24.0% 47.1% 15.3% 28.2% Practice 14 27.0% 23.0% 33.3% 11.1% 22.2% Practice 15 23.5% 20.8% 64.3% 3.6% 17.9% Practice 16 28.2% 32.1% 63.2% 10.5% 5.3% Practice 17 29.1% 27.8% 52.9% 8.4% 16.0 % Practice 18 33.8% 15.7% 50.0% 10.5% 37.5% Practice 19 35.0% 28.2% 46.7% 13.3% 26.7% Practice 20 27.6% 18.4% 51.3% 11.0 % 22.0%

My Choices, My WishesSM

My Choices, My Wishes SM - The Mission Support a culture of patient and practitioner shared decision-making, assuring that patient values are addressed and understood when difficult decisions need to be made and that patients with life-limiting illness have documented care directives included within the health record. Advance care planning leads to*: Increased use of hospice and palliative care Less aggressive care in the last six months of life More efficient use of resources and, most importantly Improved comfort and satisfaction for patients and families SOURCE: *Wright AA et al. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 300(14),1665-1673. doi: 10.1001/jama.300.14.1665. 26

Values-Based Advance Care Planning My Choices, My Wishes is an ongoing and systematic process for supporting informed decision making in advance care planning and end-of-life discussions Key Components Validated patient values survey instrument Automated identification of target population (from EHR) Scheduled counseling appointments with trained staff Standardized patient education materials ACP documentation tools in EHR Performance outcomes reporting metrics 27

Program Benefits Effective use of hospice and palliative care Less use of aggressive care in the last six months of life More efficient use of practice and patient resources Higher levels of comfort and satisfaction for patients and families 28

Patient-Centered Values Assessment 29

Practice Insights

Quality Measures

Oncology Care Model Performance Measures

Texas Oncology Strategy for Managing Value Based Contracts Quality improvement Hospitalization and ER visit control End of life care/advance care planning to improve hospice utilization Quality metrics Cost decrease Pathways Growth factor utilization Shared decision making 33

3 Integrated Treatment Plan

Integrated Treatment Plan Integrated with iknowmed Documents Six IOM Care Plan Points of Care 1 Relevant Patient Information 2 Diagnosis, biomarkers, stage 3 Prognosis 4. Treatment Goals 5 Treatment Plan and Duration 6 Expected Response

3 Integrated Treatment Plan

Utilizing Data for Practice Transformation Motivating change Delivering and accepting personalized data Communication strategies Structure in a geography dispersed group Handling outliers and consistent nonperformers

Participation Sprint to Performance Marathon Continuous Transformation

Types of Resistance to Performance Data Donald L Anderson Organization Development: The Process of Leading Organizational Change. Sage Publications, 3 rd edition

More Detail : focuses only on wanting more data, more explanation Flood you with explanations: the physician spends most of the meeting talking, providing history, commentary and tangential issues of the why of what you are trying to present to them. Time: the physician never has enough of it. To do the work, to meet and review to discuss their metrics Impracticality: the physician talks about how this is impractical, how it s a nice theory but it wont work here I m not surprised : The physician seemingly accepts the feedback, but are avoiding the discomfort that arises from receiving difficult feedback. Attack: direct attack on the one that brings the data

Confusion: much like a desire for more information, the MD wants another explanation, expressed in a different way. Then this seems unclear and another is requested and so on. Silence Intellectualizing: MD attacks the underlying theory, desiring more articles or models that apply to the situation. Instead of planning or discussing action, the MD philosophizes about the organization and the theoretical. Moralizing: the physicians wants to blame others, often the group, stating what they should be doing or what the group doesn t understand. It shifts the focus from the physician s actions and sets up a hierarchical and non-cooperative situation.

Compliance: A physicians seems too willing and agreeable and not appropriately upset to the situation (if it is difficult). Behind the agreement are the physician s doubts and reservations. When its time to take action, the physician delays. Methodology: questions about method represent legitimate needs for information in the first 10 minutes. Flight into health : It becomes easier to ignore the problem or change one s opinion of it than to risk trying to address it. Pressing for solutions: the physician expresses frustration at any additional explanation about the problem, pressing the change agent to get to the point where solutions are described. If the physician does not understand the problem they are less likely to solve it effectively

The Secret of Change Is to Focus All of Your Energy, Not on Fighting the Old, But on Building the New Socrates

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