1. 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

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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Performance Measurement

18. 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

19. Internal Perception

20. Measured Reality

21. “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 ~ 21

22. Strategic Goal

23. 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

24. 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

25. 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

26. Oncology PCMH Model

27. 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

28. 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

29. 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

30. 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

31. Results

32. 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

33. 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

34. 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

37. 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% – 2010 (practice)
Individual physician performance followed
Pathway Compliance
Small number of patients > 80%

38. 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

39. 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

40. End of Life Care Data Hospice Average Length of Stay:
2009: days
2010: days
2011: 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

41. Oncology PCMH Impact on Cost of Cancer Care
Projected % Reduction in Cancer Care Cost
Chemotherapy pathways program
Inpatient hospitalizations (5-25% reduction)
ER evaluations (20-40%)
Diagnostics
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

42. Replication

43. 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

44. 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

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

46. 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

47. Stakeholder Perspective

48. 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

49. 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

50. Questions
For more information about Oncology Patient Centered Medical Home: John Sprandio Susan Tofani