Oncology Patient-Centered Medical Home® Business Case for Quality Value Based Hematology and Oncology Care John D. Sprandio, M.D., FACP Consultants in Medical Oncology & Hematology, P.C. Oncology Management Services, LLC. Philadelphia, PA

Agenda Rocket Science, Physician role, PCMH, Cancer Performance Measurement Oncology PCMH Model Results Replication Stakeholder Perspective Conclusion – it’s not just about Cancer

Rocket Science Physician’s Central Role Primary PCMH Focus on Cancer Care

What’s Wrong with the US Health Care Delivery System? Continuum of health care science Basic science – unravels mysteries Translational research – develop new treatments Policy analysts – measure outcomes Fundamental Question: How is care best delivered? Dartmouth Center for Health Care Delivery Science “The real rocket science now in health care is cost and quality.” Dr. Jim Yong Kim

US Health Care Focus on Cost: 2012 health care costs $ 2.8 trillion Taken alone = the worlds 5th largest economy We outspend the rest of industrialized world 90% on rescue, 10% on chronic care verses 50/50 Targeting waste due to failures in: Delivery Pricing Coordination Administrative burden Overutilization Fraud Focus on Quality: Legislation, Regulation, Enforcement, Policy Development, Market Demands

Doing Well by Doing Good: Improving the Business Case for Quality Gosfiled, Reinertsen, et al. 2003 Physician engagement is essential in driving quality Centrality of doctor-patient relationship: Most personal & critical interaction that defines healthcare Explanation, prediction, plan of care Physicians have a broadest scope of professional jurisdiction Drive the provision of all goods and services Patient experience based on one-on-one relationship Physicians are the patient portal to the rest of the system Referrals, education, interpretation of insurance benefits

Doing Well by Doing Good: Improving the Business Case for Quality Gosfiled, Reinertsen, et al. 2003 Barriers to quality = physician “time stealers” Incentives, EMR, work-flow, decision support, niche competitors, documentation & coordination systems, outcome targets, real-time performance measurement, lack of defined PC team based model Physician work environment redesign Standardize Simplify Make clinically relevant Engage patients Fix accountability at the locus of control

Primary Care Focused Case for Quality & Value Patient Centered Primary Care Collaborative 40 year old concept: ACP, AAFP, AAP, AOA Partnership with personal physician, coordinating/integrating/documenting care, promotion of quality & safety, enhanced access, whole person orientation, reduced acute events, reduced utilization, and improved outcomes NCQA emerged as one standard setting entity 9 Standards 3 levels of recognition Improved Value reported 2010 and 2012 (Grundy, et al) Reduced cost Improved clinical outcomes Improved patient and provider satisfaction

Era of Health Care Reform Transitioning from Volume to Value Value = quality/cost Enhance Quality by Increasing reliability of delivery Focus on execution (processes) of care delivery Incorporation of High Reliability Principles Control Cost by Reducing unnecessary utilization Unnecessary utilization = waste Failures of delivery, coordination, overtreatment Demonstration of results Data transparency, accountability, rapid learning

Focus on Cancer Care Microcosm of the US health care system High technology Expensive new drugs Fragmented care 1.6 million Americans diagnosed with cancer annually Direct costs exceeded $126B in 2010 0.69% of Commercially insured population 11-12% of Commercial health care spend Medicare responsible for > 50% of patients Fastest growing cost area in medicine

Focus on Cancer Care Foundation of medical home and accountable care organizations has been primary care oriented Complex care outside the scope of primary care requires delegation to specialists (cancer, nephrology, etc.) How does the Primary PCMH or ACOs manage cancer costs if the patient is transferred to oncology? Oncology Patient-Centered Medical Home® (OPCMH) model has generated broad interest following recognition by NCQA in 2010 Oncology PCMH projected to reduce cancer spend

Era of Cancer Care Reform Provider Accountability “Only those giving the care can improve it” Failure to control cost (waste, site of care) Diminishes Value Results in further funding cuts Unintended clinical consequences for the most vulnerable Reduced access, increased co-pays, reduced compliance Standardization of delivery = waste reduction Chemotherapy guidelines & pathways Care delivery beyond chemotherapy selection Requires practice transformation

Improving the Business Case for Quality CMOH 2003-2013 Principles of re-designing cancer care delivery: Standardize/Streamline (variation in process of care) Simplify payment and administrative systems Minimize clinically irrelevant physician activity (Make complex decisions & maintain personal relationships) PCMH (engage, educate, access, coordination) Accountability at physician-patient locus (care team) Ongoing data driven process improvement

CMOH: 2009 – 2013 Making a Business Case for Quality Focus on demand to improve quality and value Led to development of OPCMH model NCQA PCMH recognition & QOPI certification Opportunity to lead positive change Prepare for future payment models Episode based, bundles, budgeted payment system Prepare for future organizational structures ACO, Hospital System/Payer hybrids, independent practices, large single TIN networks, Clinically Integrated Networks, etc

Lessons from Medicare Demonstration Projects CBO Issue Brief January 2012 6 Disease Management & Care Coordination Demonstrations Goal: Improve the quality of care for costly, chronic illnesses In nearly all 34 programs spending was unchanged or increased All had 3rd party care management vendors involved Number of programs focusing on cancer care – none 4 Value-Based Payment Demonstrations Goal: Improve quality and efficiency via financial incentives 1/4 bundled payment programs resulted in 10% Medicare savings Successful program operated at a loss

Lessons from Medicare Demonstration Projects CBO Issue Brief January 2012 Take Home Message Changes in payment & delivery systems are necessary Timely data on use of care (potentially avoidable complications) Focus on transitions of care (Hospital discharge; primary to specialist) Physician-led team-based care (physician, nursing, navigators) Integrate management systems (minimize vendors) Target high-risk patients – predictive modeling Rigorous design, concrete answers facilitates rapid learning cycle Potential for successful re-designing care delivery in oncology Physician-lead Care Management Team + Patient engagement Promotion of Physician Accountability at the point of delivery Timely data driving a rapid learning cycle

Performance Measurement

The Four Habits of High-Value Health Care Organizations Everyone believes they are delivering “high quality, highly reliable care” Specification and Planning Micro-system design Measurement and oversight Commitment to ongoing process improvement Richard Bohmer, M.B.,Ch.B. NEJM 12/1/11

Internal Perception

Measured Reality

“Eminence Based Medicine” © Kaufman Strategic Advisors, LLC KAUFMAN:Crozer_Jan 5-6_2012 NK1(2.0).ppt “Eminence Based Medicine” Providing sub-optimal medical care with increasing confidence over an impressive number of years. ~British Medical Journal, Vol. 1 Sept 2001 3/31/2017 © Kaufman Strategic Advisors, LLC Prepared by Nathan S. Kaufman ~ n8@KaufmanSA.com 21

Strategic Goal

How can a physician-led care team reliably deliver cancer care? Critical Provider Solutions Standardized process of care and data collection Presentation of consumable data, decision support – with each patient interaction Documentation tools to relieve the burden on a physician’s ability to execute care consistently Standardized communication Real time performance data

IRIS Software Suite Physician-Centric Software Enabling Patient-Centered Care Clinical Decision Support System (CDSS) Work-flow integrated with delivery, documentation & MU Speech-recognition integrated into work-flow Immediate document completion and auto-dissemination Physician performance reports Physician document and lab management review Longitudinal performance status & NCI graded symptom tracking Triage outcomes & Unscheduled visit tracking Personalized Patient Assessment and Verification Tool Enhanced Patient Queuing/tracking program Individual patient test result and appointment tracking Screening and Immunization prompts Portal access for patients and referring physicians Palliative and End-of-Life Care Management prompts Enables PCMH-N functionality

Quality, Service & Delivery Parameters ASCO - QOPI standards NCCN Guidelines American College of Surgeons NQF, NCPF, NCCS, ONS CMS - PQRS, e-Rx NCQA – PPC-PCMHTM OPCMH – services Institute of Medicine 1999 Ensuring Quality Cancer Care 2001 Improving Palliative Care for Cancer 2006 From Cancer Patient to Cancer Survivor: Lost in Transition 2009 Assessing & Improving Value in Cancer Care 2012 Best Care at Lower Cost

Oncology PCMH Model

Oncology Patient-Centered Medical Home® Model Re-engineered Process of Care & Coordination Ownership of all aspects of cancer care delivery Focus on patient needs and evidence-based care Reduction in unnecessary variation & resource utilization Enhanced communication with PC PCMH & Specialists Real-time physician/practice performance measurement Continuous process improvement Encourages Clinical Integration between practices

Oncology Patient-Centered Medical Home® Based on NCQA PPC-PCMHTM NCQA Standards drive Quality, Service & Utilization Enhanced Access & Continuity Identify and Manage Populations Plan and Manage Care Self-care Support & Community Resources Track and Coordinate Care Measure and Improve Performance

Process Measurement Rapid Learning Cycle Function of mutually reinforcing care-team Interdependent roles, responsibilities, and hand-offs Merging Work-Flow & Clinical Decisions Guidelines, staging, screening, prevention Triage & Symptom Management algorithms Communication/Documentation turn around Patient Navigating/tracking tests & referrals Performance Status & Palliative Care tracking End of life care/promoting shared decisions Patient & Physician portal utilization Management of at risk populations

Patient & Payer Centered Outcome Measures Patient Experience AHRQ CAHPS: Consumer Assessment of Healthcare Providers and Systems Outcomes Staging compliance Chemotherapy guideline adherence Emergency Room evaluations Hospital admissions / length of stay Outpatient visit reduction End of Life Care parameters Diagnostics: imaging & laboratory

Results

NCQA PCMH & The Four Habits of High-Value Health Care Organizations “The ability to disseminate and deliver high value clinical innovation is based on similar, portable habits of care management … implemented simultaneously” Richard Bohmer, M.B.,Ch.B. NEJM 12/1/11 Specification and Planning Merging operational and clinical decisions with documentation Micro-system design Matching subpopulations and pathways, triage algorithms Measurement and oversight Targeting internal operational issues – drive outcomes Commitment to ongoing process improvement Insights for better outcomes fuels modification of Specification and Planning

USON/Milliman: Approximately 1 hospital admission per chemotherapy patient per year (n=14 million commercially insured; 104,473 cancer patients) Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009

USON/Milliman: Approximately 2 emergency room visits per chemotherapy patient per year (n=14 million commercially insured; 104,473 cancer patients) Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009

Guideline & Pathway Adherence Chemotherapy care plans are NCCN compliant Deviation requires customization (controlled) Physician selects care plan within EMR Selection shared with billing and nursing staff NCCN Compliance Adjuvant and first line metastatic Adherence > 95% 2007 – 2010 (practice) Individual physician performance followed Pathway Compliance Small number of patients > 80%

OPCMH End-of-Life Care Collaborative Dartmouth OPCMHTM QOPI Measure Death in hospital % X PH numerator; denominator ? Practice* Hospital admissions, last 30 days, % ICU admissions, last 30 days, % ICU Days, last 30 days ChemoRx, last 30 days Hospice, last 30 days, % Hospice days, last 30 days Hospice within 7 days of death, % Hospice enrollment, % ACP discussion with metastatic disease PH numerator and denominator Advanced care plan documented, % Practice ECOG performance status documented at each visit

OPCMH End of Life Care Performance Status Driven Influences ongoing treatment decisions Standardized assessment & longitudinal tracking of PS Impact of disease & therapy on abilities, QOL Auditing for PS decline (ECOG 3) Ongoing Discussion of Goals of Therapy Documentation at onset of stage IV disease Documentation of ongoing discussion with decline in PS, change in therapy Goal: Promote shared decision-making

End of Life Care Data Hospice Average Length of Stay: 2009: 26 days 2010: 32 days 2011: 35 days Place at time of death: 70% home 2010 74% home 2011 ER visits & hospital admissions last 30 days of life: 2010: 39.3% total practice Admissions 2011: 36.4% total practice Admissions 2010: 23.8% total practice ER visits 2011: 20.1% total practice ER visits 34% increase

Oncology PCMH Impact on Cost of Cancer Care Projected % Reduction in Cancer Care Cost 1-3 Chemotherapy pathways program 4-6.3 Inpatient hospitalizations (5-25% reduction) .6-1.1 ER evaluations (20-40%) .1-.4 Diagnostics .9-1.9 End-of-life care coordination Total 6.6 – 12.7 % reduction Annual cancer “spend” $125B = $8-16B savings Adapted from international consultants evaluation of OPCMHTM application to cancer care

Replication

Replication of the Model Four Key Steps Specialty societies define quality parameters ASCO, ACOS, NCCN, COA, NQF, NCPF NCQA Specialty Practice Recognition Program Application of PCMH principles to specialties Specialty Practice standards March 2013 Payer engagement and support Regional and national payers Phases of construction of PC-SP Payer Incentives & Practice Deliverables defined

NCQA PC-SPR Transformation vs other Quality Improvement models NCQA Standards are based on: Service, quality, utilization, meaningful use Standardized processes across practice Re-defined roles - supporting a physician-led team Promotion of physician efficiency & accountability Applicable to Oncology, Nephrology, Cardiology, Rheumatology

Level of Oncology Accountability Models for Payment of cancer care FFS Pathways OPCMH Bundled or Episode Payment

Oncology Patient-Centered Medical Home® Value Proposition OPCMH – clinical & business methodologies Data driven practice/patient care efficiencies Community and hospital-based practices OPCMH - organizational construct Oncology “plug-in” to PCMH as a PCMH-N Establishes care management accountability Communication that bridges specialists and PCMH OPCMH – as PCMH bridge Aligns oncologists for ACO, Clinical Integration, etc Platform for pricing bundles, episodes, etc or episode of care payment

Stakeholder Perspective

Patients & Payers Want Reliable Patient-Centered Services Personal relationship with a physician Explanation, Prediction, Plan of intervention “On demand” access to care & information Total coordination of all aspects of care Communication among all providers of care Best possible outcomes Improvement & preservation of quality of life Fewer complications, ER, hospital admissions, visits Fewer co-pay related events Rational care at the end of life

Summary Foundation of PCMH and ACOs are primary care oriented Costly care exists outside the scope of primary care Primary care delegates management of complex care (cancer, nephrology, etc) to specialists The specialty community has the capacity to dramatically improve care and reduce costs This requires practices to transform the way they deliver care, which requires stakeholder collaboration Payers need to promote physician driven efforts to enhance value & continuously improve care delivery

Questions For more information about Oncology Patient Centered Medical Home: John Sprandio jsprandio@cmoh.org Susan Tofani STofani@oms-support.com www.OPCMH.com