1. Delivering Value-Based Cancer Care in the Community J. Russell Hoverman, MD, PhD Vice President, Quality Programs

2. Exponential Growth of Computing 2 Source: www.singularity.com/charts/page70.htmlwww.singularity.com/charts/page70.html

3. Figure 1. Average Medical Oncology Charge per Patient, Age < 65, 1 Standard Deviation Physicians Average Charge/Patient Figures for Lung Cancer A Retrospective Study

4. Average Charge/Patient Department Chemo Lab Medical Pharmacy Overall Admin Professional Avg. Upper Group 10 Physicians Average (77 patients) Composite Average (318 patients) Lower Group 10 Physicians Average (74 patients) Figure 3. Segregation of Charges by Department, Age < 65 Figures for Lung Cancer A Retrospective Study

5. Figure 7. Survival - Extensive NSCLC, P=.99 Survival Extensive Non Small Cell Lung Cancer Years Survival Distribution Function STRATA:group = Lowergroup = Uppercensored group = Upper 1.00 0.75 0.50 0.25 0.00 0.00.51.01.5 2.0 2.5 3.0 3.5 Figures for Lung Cancer A Retrospective Study

6. Exponential Growth of Computing 6 Source: www.singularity.com/charts/page70.htmlwww.singularity.com/charts/page70.html

7.  Taxol/Carboplatin 41%  Taxotere/Carbo32%  Gemzar + a taxane3%  Cisplatinum/Navelbine1%  Gemzar/Carbo19%  Other4% Source: *Network for Oncology Communication and Research Oncology Case Series: NOCR* 1 st Line Stage IV NSCLC

8. 8 KCCC: From 1/1/06 to 9/1/06 NSCLC Treatment by Stage

9. 9

10. 10 Source: Neubauer, Cost-Effectiveness of Evidence-based Treatment Guidelines for the Treatment of NSCLC in the Community Setting, JOP, 6:1. 12-Month Cumulative Cost by Pathway Status

11. 11 Neubauer, Cost-Effectiveness of Evidence-based Treatment Guidelines for the Treatment of NSCLC in the Community Setting, JOP, 6:1. Overall Survival by Pathway Status

12. Integrates with physician’s workflow:  Imports patient and clinical data from commonly-used EHRs Identifies relevant Value Pathways and NCCN Guidelines at point of care Allows providers, payers and employers to align on quality and value in patient care A New Technology Standard: Clear Value Plus software to streamline demonstration of quality

13. Exponential Growth of Computing 13 Source: www.singularity.com/charts/page70.htmlwww.singularity.com/charts/page70.html

14. Innovent Oncology – The Solution Addressing the Three Major Cancer Care Cost Drivers 14 Level I Pathways Reduced variability in treatment patterns Reduced costs of drugs, Reduced medication errors Improved clinical efficiency Increased patient and caregiver satisfaction Expected Results Quality Reporting and Outcomes Data Analytics Patient Support Services Reduced hospitalizations Reduced ER visits Increased adherence to treatment plan Encourages patient self- management Increased patient and caregiver satisfaction Expected Results Advance Care Planning Reduced costs of treatment near end of life Increased hospice utilization Improved symptom management Documentation of patient’s values and goals of treatment Increased patient and caregiver satisfaction Expected Results

16. Aetna Innovent Commercial Pilot 2010-2012 16 Study Design Prospective, non-randomized evaluation of patients enrolled in the Innovent Oncology Program LocationPatients seen by Texas Oncology physicians Study period Innovent Oncology Program 6/1/2010-5/31/2012; Program yr 1: 6/1/2010- 5/31/2011; Program yr 2: 5/1/2011-4/31/2012 Inclusion Aetna eligible pts diagnosed with an Innovent diagnosis initiating chemotherapy during program year 1 or year 2 Drug costs ER and in-patient admissions and costs Exclusion Patient eligible for the program in the last month of each program year Patients with a chemotherapy claim in the month prior to the program year Patients without a chemotherapy claim within each program year

17. Results of Aetna commercial pilot ER visits reduced by 38% Year 1, 52% Year 2, & 48% overall for the program In-pt admissions reduced by 16% Year 1, 50% Year 2, & 34% overall for the program Hospital days reduced by 36% Year 1, 51% year 2, & 44% overall for the program Pathway adherence was 74% in the Innovent program and 63% prior to initiating the program Total savings calculated: $506,000

18. Value Value Formula V = O/C

19. Value Relative Value RV1 = O1/C1 RV2 = O2/C2 RV3 = O3/C3

20. Subjective Data  Relative value may be determined by subjective value, assessable only by the patient.  True value to the patient cannot be determined unless subjective values are explored.

21. Patient Support Services 21  OCN with outbound calls at chemo start. Reviews meds, side effects, ESAS, Advance Directives.  Scheduled calls thereafter with frequency determined by risk.  Referral to clinic for any concerns based on assessment algorithms.  Notes appear in medical record  Values Assessment and Advance Care Planning  Scanty evidence base for PSS although CCO study demonstrated 35% reduction in hospital days with regular ESAS.

22. Value Assessment and ACP 22  Experience with over 800 Value Assessments  Little pushback  Transition to decision making  Too soon to measure impact

23. (Sample)

24. Value Assessment 24

25. Advance Care Planning* 25 ACP Introduced 90% ACP Counseling 60%** ** Of total enrollees (n=202) Compare to Q3: ACP was 85% enrollees Introduced and 60% enrollees Participating in Counseling *From one of our currently operational Innovent programs

26. Critical Communication  Temel JS, Greer JA, Muzikansky A, et al. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer N Engl J Med 363:733-742, 2010.  Wright AA, Zhang B, Ray A, et al. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death and Caregiver Bereavement Adjustment. JAMA 300:1665-1673. 2008.  Kalisiak A, Hedlund S and Gandara E. Positive Impact: Integrating Palliative Care Education and Support in a Community Oncology Practice. J Pain Symptom Manage 41:289, 2011.  Lundquist G, Rasmussen BH and Axelsson B. Information of Imminent Death or Not: Does It Make a Difference. J Clin Oncol 29:3927-3931, 2011.  Hammes BJ, Rooney BL. Death and End-of-Life Planning in One Midwestern Community Arch Int Med 158:383-390. 1998  Mack JW, Conin A, Keating NL et al Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study 26

27. Exponential Growth of Computing 27 Source: www.singularity.com/charts/page70.htmlwww.singularity.com/charts/page70.html

28. The Medicare Population 28

29. Cautions  Any program will require re-engineering practice  Greater opportunity for savings with expanded program  Costs for personnel and infrastructure regardless of model 29

30. Next Year and the Year After  Collect data  Streamline processes  Negotiate for more management opportunities  Link physician income to performance  Understand operational costs including data collection and analysis  Explore new methods of retrieving and organizing information to develop risk prediction models’ 30