1. Next steps in oncology payment reform
Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Next steps in oncology payment reform
Michael Kolodziej, M.D., FACP
National Medical Director, Oncology Solutions
Aetna

2. Aetna Values & Oncology Solutions Mission Statement
Aetna Oncology Solutions – Mission Statement:
We give our members access to high-value, personalized cancer care models. We collaborate with oncology teams that deliver best-in-class care by using evidence-based medical guidelines, clinical decision support tools and services that improve the patient’s experience, increase effectiveness of care and lower costs. Our value-based approach, powered by data analytics and transparency of policy and payment, allows us to move from a fee-for-service platform to a value-driven system that rewards Oncology practices for quality care throughout the patient’s care journey.

3. Payers are horrified by the cost of cancer care and perceived low value

4. Responses to the huge and growing expense of cancer care?
Pay less
Manage more (prior auth)
Narrow networks
Shift responsibility to member (co-pay)
Pay for performance (process measures)
Shift risk (capitation)
Impact has been small
Aggravation has been large

5. Who are the players and why
The practice perspective: size, sophistication, personality The payer perspective: size, sophistication, personality CMS has changed the playing field

6. You cannot improve a process that is not measured
BREAST
ABC ONCOLOGY - BREAST
2012
2013
COMMERCIAL
MEDICARE
Grand Total - FOCUS BCL MEMBERS
542 6
548 93
FOCUS MBR CHEMO COSTS AT PRAC (TIME PERIOD)
$12,336,674
$24,740
$12,811,033
$898,159
AVG PMPY
$22,761
$4,123
$23,378
$9,658
ACTIVE CHEMO MBR PRAC
2,707 18
2,658
407
ACTIVE CHEMO PRAC
$4,557
$1,374
$4,820
$2,207
AVG ACTIVE CHEMO MONTHS SEEN**
5.0
3.0
4.9
4.4
IP FOCUS MBR AVG LOS
AVG LOS
4.99
6.50
5.69
7.04
ER VISITS PER FOCUS MBR
PY VISITS
1.60
1.00
1.49
FOCUS MBR YRLY MCC COSTS (SEE BELOW)
$26,510,932
$94,050
$28,019,064
$2,325,577
AVG FOCUS MCC COST
PMPY
$48,913
$15,675
$51,130
$25,006
FOCUS MCC CATEGORY BREAKDOWN
AMB FACILITY - UPMPY
UPMPY
$6,489
$690
$7,118
$1,555
EMERGENCY - UMPY
$2,560 $0
$3,494
$624
IP FACILITY - UMPY
$22,842
$169
$26,037
$20,476
LAB - UMPY
$700
$972
$808
$389
MEDICAL RX - UPMPY
$35,125
$9,735
$36,296
$18,349
RADIOLOGY - UPMPY
$10,959
$7,900
$11,053
$4,926
SPEC PHYSICIAN
$2,237
$1,198
$2,699
$2,042

7. Where are we now?
Pathways (get over it) Pay for value

8. What is the role of the consumer?

9. What are the threats?
Cost of innovation Consolidation of providers

10. Copyright © 2015 American Medical Association. All rights reserved.
From: Five Years of Cancer Drug Approvals:  Innovation, Efficacy, and Costs
JAMA Oncol. Published online April 02, doi: /jamaoncol
Copyright © 2015 American Medical Association. All rights reserved.

11. Where are we going?
Episode based reimbursement

12. Cost of Care is Greatest During Periods of Active Treatment

13. There is tremendous consistency across disease states

14. Episode fee plasticity based on clinical performance
Basic Episode Fee
Reduced Episode Fee
Enhanced Episode Fee
Determinants of modifier:
ER visits, Hospitalizations, Generic prescribing, Hospice Enrollment

15. The challenge is managing high-cost outliers

16. The Oncology Patient Centered Medical Home: Aetna Pilot Experience Proprietary & Confidential