Brass Tacks: The Money Problem R. Maziarz, MD AGFBT Meeting 10/20/2016

Financial Disclosures

Objectives Identify opportunities for research in improving value and emerging reimbursement models Summarize the predicted impact of MACRA and the Oncology Care Model Evaluate the CIBMTR 3-year survival metric and value

Baseline: Big Price Tags Bring Big Problems

Getting Down to Brass Tacks Brass tacks are a type of pin or nail, sometimes called a drawing pin. In colloquial English, the phrase to get down to brass tacks is an idiom that means to focus on essential details, such as measuring out the precise amount of an item for sale. Brass Tacks for the AGFBT = What’s the societal ROI? Value of HCT Emerging Reimbursement Models

Value= Health outcomes that matter to patient What is Value? Value proposition= Expensive, but potentially curative Value = Quality/Cost Value= Health outcomes that matter to patient Cost of Delivery Adapted from Porter 2015

Understanding the Components Health Outcomes that matter to patients Survival – OS and PFS Self-reported QOL Return to work/normal Financial Toxicity Cost of Care Delivered Claims data analysis Evidence-based care Unnecessary waster HSR Working Groups, PCORI Efforts HSR/HE SIG Efforts Research, Guidelines AGFBT Subgroup

Defining Waste American Society for Quality (ASQ) = “healthcare services that do not add value or improve patient outcomes”

Can we identify how much waste exists in HCT? Starting Points: Milliman Estimate of Auto and Allo HCT costs PMPM = $3.33 2010 LifeLink data total average monthly spend PMPM = $320 $750 Billion in Waste 3.33 320 = 𝑥 750,000,000,000 = $7,804,687,500

$7,804,687,500 Seems Rather Dramatic Ok - Let’s assume HCT is dramatically better than average $7,804,687,500∗.01=$78,046,875 Average Transplant Episode Charges = ~$1 Million $78,046,875 $1,000,000 =78 Do we waste the equivalent of 78 transplants per year?

Categories of Waste Administrative Complexity Failures of Care Delivery Adverse Events, HAIs, Misdiagnosis Failures of Care Coordination Readmission, Decline in Functional Status Overtreatment Defensive medicine, provider preference, futile care Administrative Complexity Unstandardized forms and procedures Pricing Failures Above market value for no reason Fraud and Abuse Health Affairs (2012)

""Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012. http://www.healthaffairs.org/healthpolicybriefs/

Can we complete the matrix for HCT? No, but we can guess… Category Low Midpoint High Failures of Care Delivery X Failures of Care Coordination Overtreatment ? Administrative Complexity Pricing Failures

Other Potential Categories HCT-specific care practices: Labs Medications LOS variation Variation in patient selection Variation in donor selection Care-setting variation (IP vs OP) Time to consult Time to transplant Examination of Outliers – Commonalities?

IOM Recommendations on Countering Waste “ICU clinicians have 180 activities per patient per day” Improve providers' capacity to collect and use digital data to advance science and improve care. Involve patients and their families or caregivers in care decisions. Use clinical practice guidelines and provider decision support tools to a greater extent. Promote partnerships and coordination between providers and the community to improve care transitions. Realign financial incentives to promote continuous learning and the delivery of high-quality, low-cost care. Improve transparency in provider performance, including quality, price, cost, and outcomes information. IOM, September 2012

New Reimbursement Models: MACRA, MIPS, OCM

The Main Idea: Incentivize MD Care Choices CMS-created systems of adjusting MD payment based on quality and cost MACRA – goes into effect in 2017 MIPS and other measures of ‘quality’ Oncology Care Model and episode payments (cardiac, knee/hip) can substitute as Alternative Payment Methods Many commercial/government payers outside of CMS adopting OCM Tracks cost of care in 6 months after initial outpatient treatment Compares against historical baseline; MDs win/lose based on the Δ Supposed to have exceptions for ‘breakthrough therapies’

Oncology Pathways Summary Pathways developed from national guidelines Take into account: Clinical benefit Toxicity Cost

Oncology Pathways Benefits: Based on established guidelines, enhanced reimbursement

Oncology Pathways Drawbacks: Prescribed pathways don’t necessarily allow physician subjective judgment; different pathways with different payers

Oncology Pathways Applicability to HCT: Would require HCT community input with payers on a regular basis. Suggestion—patients selected for a pathway automatically preauthorize for care

Oncology Pathways Example

Reimbursement Model Survey Model Name Summary Benefits Drawbacks Applicability to HCT? Oncology Pathways Pathways developed from national guidelines taking into account clinical benefit, toxicity and cost Based on established guidelines, enhanced reimbursement Prescribed pathways don’t necessarily allow physician subjective judgment; different pathways with different payers Would require HCT community input with payers on a regular basis. Suggestion—pts selected for a pathway automatically preauthorize for care

Oncology Pathways References BCBS Pathway experience, n= 4,713 $10.3 million in savings http://www.ncbi.nlm.nih.gov/pubmed/23943896 Oncology Pathways—Preventing a Good Idea from Going Bad http://oncology.jamanetwork.com/article.aspx?articleid=2485187

CMS Oncology Care Model Multi-Payer program run through CMS PBPM payment for managing care (Medicare FFS) OCM follows 6 month episodes of care costs; triggered by initial chemo claim Performance-based payment paid out dependent on quality measure achievements Incentive to lower the total cost of care and improve QOL

Oncology Care Model References http://jop.ascopubs.org/content/11/2/114.long

Impact of MACRA/OCM on HCT Team sports (like HCT) do not fit neatly into MACRA blueprint Will patients who need transplant or other high-cost care become undesirables? Initial years have limited risk, but substantial dollars in play by 2020