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

2. Financial Disclosures

3. 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

4. Baseline: Big Price Tags Bring Big Problems

5. 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

6. 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

7. 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

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

9. 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
= 𝑥 750,000,000,000 = $7,804,687,500

10. $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?

11. 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)

12. ""Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012.

13. 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

14. 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?

15. 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

16. New Reimbursement Models: MACRA, MIPS, OCM

17. 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’

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

19. Oncology Pathways
Benefits: Based on established guidelines, enhanced reimbursement

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

21. 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

22. Oncology Pathways Example

23. 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

24. Oncology Pathways References
BCBS Pathway experience, n= 4,713 $10.3 million in savings
Oncology Pathways—Preventing a Good Idea from Going Bad

25. 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

26. Oncology Care Model References

27. 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