2. Alternate Payment Methodologies: Building and Costing Care Bundles
Mark Sobczak, MD Fox Chase Cancer Center Philadelphia, PA Moderator

3. Speakers Constantine Mantz, MD, 21st Century Oncology
Therese Mulvey, MD, SouthCoast Health System
Khanh Nguyen, PharmD, Hill Physicians Medical Group
John Steiner, Esq., Cancer Treatment Centers of America

4. Alternate Payment Methodologies: Building and Costing Care Bundles
John Steiner, Esq. Chief Compliance & Privacy Officer and Associate General Counsel, Cancer Treatment Centers of America

5. Alternate Payment Methodologies: Building and Cost Care Bundles
Presented by: John Steiner, Esq.
Chief Compliance & Privacy Officer
and Associate General Counsel

6. Bundled Price for Evaluation of Patients with Breast, Lung, Colorectal and Prostate Cancers
Premise:
Empower patients (consumers) to control personal healthcare decisions; decrease reliance on government
© 2011 Rising Tide

7. CTCA Vision for a Bundled Price Evaluation
Allow a consumer – driven oncology marketplace to thrive
Consumer choice based on informed judgments of the value of providers’ services
© 2011 Rising Tide

8. Consumer Judgments Require transparency of: Product quality
Convenience
Consistency of delivery
Price
A bundled evaluation is an important step for empowering consumers
© 2011 Rising Tide

9. Our Patient Empowered Care (PEC) Model
CTCA is unique in that our patients are examined by several billable providers on the same day. This model of care increases:
the importance of compliant documentation that tells the patient story,
quickly provides relevant information to the succeeding provider, and
supports billing.
Often CTCA patients are seen by the Intake doctor, the medical oncologist, the naturopath, and a radiologist all on the same day, as well as several non-billable providers. Clinical documentation by each provider must support medical necessity for that specific encounter, and avoid looking cloned.
We will talk about the different functions you can use within the E H R to accomplish this.
I would also encourage you to complete the Computer-Based Learning (CBL) courses we created where you can earn CME.
© 2011 Rising Tide

10. Value- based cancer diagnostics and treatment plan.
Objective: Provide payers and patients with a complete, comprehensive diagnostic evaluation and a personalized treatment plan within 3 to 5 days at a set price.
In 2012, limited to the diagnostic and treatment planning phase of cancer care vs. treatment phase
© 2011 Rising Tide

11. Limitations on Set Fee Pricing
Participating patients in the bundled price evaluation must be identified in advance (no retro-active application of set fee pricing)
© 2011 Rising Tide

12. Excluded Services
Bundle excludes treatment of co-morbid conditions and emergencies due to other medical conditions that may require treatment while patient is at a CTCA facility for an evaluation
e.g. Diabetes, Myocardial Infarction – and their sequelae
© 2011 Rising Tide

13. Lung, Breast, Prostate, Rectal and Colon cancers. Components:
Medical Oncologist Consultation
Imaging / Pathology Services
Medically necessary, per the medical oncologist, to provide an appropriate evaluation
© 2011 Rising Tide

14. Nutritional Consultation
Evaluation by a registered dietitian with experience serving cancer patients
Related lab tests and a plan to keep the patient well nourished, prevent malnutrition, rebuild body tissue and support immune function while ongoing treatment
© 2011 Rising Tide

15. Naturopathic Consultation
Evaluation by a naturopathic provider certified in oncology
Development of a plan to support normal metabolism, boost the immune system and alleviate treatment-related side effects
© 2011 Rising Tide

16. Mind-Body Medicine Consultation
Licensed health professional experienced with help in cancer patients cope with their disease, regain and maintain a sense of control of their lives and treatment
Specialist Consultations (as needed)
Radiation oncologists / Surgeons /
Pain management / Interventional Pulmonologists/ others
© 2011 Rising Tide

17. Treatment Plan Development and Review
Comprehensive, integrated treatment plan tailored to the patient’s needs; developed by the patient’s oncologist and care team working together at the patient’s side.
© 2011 Rising Tide

18. Also included:
Consultations with allied health professionals, as appropriate, e.g. rehabilitation therapy, chiropractic care, acupuncture and pastoral care
Transportation, lodging and meals for patient and companion
Care management, patient relations, patient scheduling and travel planning
© 2011 Rising Tide

19. Recap
Bundled price for evaluation of Breast, Lung Colorectal and Prostate Cancers
Patient empowered care/consumer choice based on informed value judgments
Composite of professional and facility services associated with a diagnostic evaluation and integrated treatment plan
© 2011 Rising Tide

20. Alternate Payment Methodologies in Oncology: Building and Costing Care Bundles
Therese M. Mulvey, MD Southcoast Centers for Cancer Care Fairhaven, MA

21. Stage IV Lung Cancer Patient Study
Therese M Mulvey, MD Southcoast Centers for Cancer Care Fairhaven, MA

22. Southcoast Health
900 in patient bed system, three hospitals and 22 ambulatory sites.
Two Cancer Centers
1500 new cases per year to SCCC
Seven medical Oncologists
Three Radiation Oncologists
Two private groups
Self Insured System of 6800 nemployees

23. Lung Study
Determine the number of admissions in the last six months of life in this vulnerable population.
Determine the AD status, hospice utilization and therapy delivered to this group.
Determine if a TME could be calculated that could provide wrap around care for this group of patients to prevent admissions.

24. Lung Cancer Stage IV High symptom burden.
Frequent hospitalizations for symptoms.
ER visit equals admission.
Multiple co morbidities associated with tobacco abuse.
Lower days on hospice than patients with other advanced cancers.
Blayney JOP 2014

25. Overview 103 Records reviewed from yrs 2009 – 2013.
Non small cell and small cell patients.
All Patients over age of 65.
Average age 75.
All patient have died.
Median OS for all patients = 4 months.
Median admission number 3.1 in last 6 months of life.
65% of admissions occur over the weekend.
16% died in Hospital.
82% had AD documented in chart before death.
90% of AD were obtained during a hospital admission 10% as an outpatient.

26. OS for Stage 4 Lung Cancer patients over 65

27. Treatment Modality and Admissions

28. Admission Rates
Excluding initial admission for diagnosis

29. Most Common Admission Diagnoses
0-3 months- symptoms of cancer.
Pain, dyspnea, hemoptysis, seizure, etc.
3-6 months- equal symptoms of cancer or side effects of therapy.
Neutropenia, nausea, vomiting, diarrhea, salt wasting, etc.
6-24 months- equal side effects of therapy and symptoms of cancer.
Equal numbers of pulmonary emboli/DVT and unrelated causes in all groups.

30. EOL State at Last Admission

31. Days on Hospice

32. Median days on Hospice per Survival Group

33. All Oncology Patients SCCC

34. Palliative Care Project
2014 addition of outpatient palliative care consults.
This service was added despite an anticipated loss in revenue vs expense.
Integrated palliative care physician into weekly rounds.
Integration of palliative care VNA team and hospice RNs to rounds and weekly MDC.
Addition of a triage nurse to call each stage IV lung patient every Friday to assess symptoms.
Financial Quality Incentive to meet QOPI standard of AD before third outpatient visit in Stage IV non small cell lung cancer patients.

35. Palliative Care
2014 data:
21 patients stage IV lung cancer, age over 65.
13 had Palliative Care consults.
5 not offered palliative care/ 3 refused
9 admissions: 4 for treatment effect, 5 for symptoms of disease.
4/5 admissions for symptoms were not actively followed by the palliative care team.
20/21 had AD prior to admission.

36. Cost Decision Analysis
We set out to determine a TME for this population of patients who had a high symptom burden and excessive numbers of admissions.
Cost analysis revealed a high net reimbursement rate in the FFS model.
TME for other diagnoses (CHF, Pneumonia) fell well below the net margin on this subgroup of patients.
The cost of the “wrap around” services outpaced the projected TME.

37. Summary
Two thirds of all individuals diagnosed with a Stage IV Lung cancer age 65 or older lived 6 months or less with a median survival of 4 months.
Symptom burden is high for this group of patients and is the most common cause of admission across all survival groups.
Palliative XRT in the 0-3 mo OS group was the primary treatment without impact on OS.
38% of all patients referred to hospice had a LOS of 1 -5 days.
74% had a hospice LOS < 20 days
Treatment with sequential or concurrent Chemo/XRT increased toxicities and hospital admissions for side effects of therapy.
Overall survival in this group mirrored other community cancer program data.
Documented EOL discussions as part of a comprehensive palliative care program appeared to reduce admissions in the 2014 data.

38. Summary
In a fee for service model there is no incentive to change the status quo.
A TME model will need to account for the high symptom burden of the disease, progression despite therapy in the last six months of life and the costs associated with a comprehensive palliative care program.
Palliative care as a stand alone program as it currently exists in a FFS setting loses money to a health system and the incentive to fully implement this program in the community is a barrier to implementation.

39. Alternate Payment Methodologies: Building and Costing Care Bundles
Constantine Mantz, MD Chief Medical Officer 21st Century Oncology

40. Learning Objectives
Describe the design and function of the first near-comprehensive episodic payment system for radiation oncology between a provider and a major commercial payer
Discuss its clinical and administrative advantages from the perspectives of patient, provider and payer
Project use of current system as a basis for more comprehensive payment reform in oncology

41. Starting Points
Fee-for-service payments create widespread inefficiency
payers spend large sums to create and enforce guidelines
providers devote substantial resources to ensure proper authorizations and billings
Measuring quality is particularly elusive in oncology
disease and toxicity outcomes become manifest over years
attribution of outcomes is not often direct
Radiation oncology’s technologic focus creates a large number of clinical decision-making branch points difficult to reduce to guidelines

42. Conceptual Framework Why providers?
Physicians are in the best position to develop the payment models that will promote care quality and efficient resource utilization
Ancillary Points:
flexibility: to allow for appropriate latitude to exercise clinical judgment and technical skill on a per-case basis
risk delegation and accountability: to separate ‘insurance’ risk from ‘performance’ risk
operational efficiencies: to reduce existing administrative and direct practice costs that do not contribute to care quality; to improve revenue cycles times and predictability

43. Conceptual Framework Why insurers? Potential Advantages
discounting
operational simplicity
clinical quality basis and performance reporting
Remaining Challenges
legacy claims processing systems
internal customer and product alignment
risk adjustments, limits and exclusions, shared savings

44. Our Goals Limit to radiation oncology
Build evidence-based/consensus-based clinical pathways for all radiation oncology cases
Thoroughly understand our own cost accounting
Develop simple mechanism for recognition of cases eligible for episodic payment
Continue FFS claims processing on both ends (provider and insurer)
Later, include quality metrics reporting based on specialty society consensus recommendations for process and outcomes as they are established

46. Episodic Payment Development
THE EPISODE PRICE
Determine diagnosis-pathway case distributions
Build business tools for modeling episode costs
Build radiotherapy pathways for defined diagnosis groups

47. Episodic Payment Implementation
Establish alternate claim submission process for provider and adjudication process for payer
Determine episode trigger, payment timing and reconciliations
Review clinical procedure content of each episode with payer’s medical advisors
Propose episode price(s) to payor

48. Conclusions
We have successfully launched and operated under an episodic payment model for radiation oncology
Resource utilization and physician prescribing behaviors remained > 98% compliant to the recommended treatment technologies and number of services modeled in each diagnosis group
Press Ganey patient satisfaction surveys administered before and after bundle implementation demonstrated consistently high overall satisfaction with a statistically significant improvement in ‘Insurance Experience’ domain satisfaction
We view our effort as a bottom-up approach, gathering development and operational know-how within a set of services we understand before participating in more comprehensive payment reform

49. Further questions and comments:
Constantine Mantz MD

50. Alternate Payment Methodologies: Building and Costing Care Bundles
Khanh Nguyen, PharmD Director, Clinical Support Hill Physicians Medical Group

51. Oncology Case Rate (OCR) Payment Reform Example
Neutral title to encourage discussion
Khanh Nguyen, Pharm.D.
Director, Clinical Support
Hill Physicians Medical Group

52. Hill Physicians Medical Group
Independent Physician Association founded in 1984
Provider network: 3,800 providers and consultants
980 Primary Care
2,260 Specialists (170 Oncologists)
Service the Northern California area
300,000 Members
5 Regions - 9 Counties

53. Oncology Case Rate (OCR) Bundled Payment System
Episode of Care Reimbursement
Cancer Cohorts by Diagnosis
Budget Set Aside for Stop Loss
Removal of Prior Authorization
Quality Management Program
Monthly episodic payment for all oncology-related services
Cost variation across different cancer types
Ensure fair allocation of risk
Reduce barriers to enable evidence-based cost-effective care
1. ASCO QOPI Measures
2. Utilization Measures
3. Satisfaction Measures
Clinical Quality Domain - ~30 QOPI ASCO Clinical Measures, Subject to Hill review/audit
Satisfaction Domain - Referring Provider Satisfaction Surveys, Patient Satisfaction Surveys
Utilization Domain - Bed Days, Infusion Center Use, Chemotherapy Initiation, ED Visits (2014)
Based on actual 3 year experience of Hill’s patient cohort
Nine separate cohorts, divided by cancer types
4 different case rates within each, based on intensity over time
Model adjusts total dollars to new expenses priced at current rates
$$ set aside for stop loss
$$ set aside for quality performance bonus

54. OCR Cancer Cohorts: Diagnosis Group by Cancer Type
Total Unique Patients, YTD 1
Colon & Rectum
116 2
Lung
136 3
Breast (female)
287 4
Ovary and other Uterine Adnexa 23 5
Prostate 41 6
Malignant Neoplasm of Other/Unspecified Sites 50 7
Malignant Neoplasm of Lymp/Hema Tissue
169 8
Other Malignant Neoplasm
158 9
Diseases of Blood & Blood-Forming Origin 27
Total Unique Patients
1,007

55. Quality Management Bonus Program
Program encompasses 3 domains
Clinical measures are subject to audit and chart reviews
Performance dashboards are shared with oncology groups regularly
Clinical Quality Domain
~30 QOPI ASCO Clinical Measures
Subject to Hill review/audit
Satisfaction Domain
Referring Provider Satisfaction Surveys
Patient Satisfaction Surveys
Utilization Domain
Inpatient Bed Days
Infusion Center Use
Chemotherapy Initiation
ED Visits (2014)

56. Claims Process & Adjudication
OCR practices submit claims to Medical Group
Claim Submis-sion
Claims processed “statistically” through claims system
FFS Adjudica-tion
Claims are rerated & case rate payments are generated
OCR Adjudica-tion
Monthly statement and check delivered to practices
Case Rate Payment
Receipt of Monthly Payment
Patient Name
DOB
Chemo Start Date
SL Threshold
SL Accumulation
Cohort
Case Rate SL
FFS
Post 3 Year
Total
Smith, A
1/1/51
10/1/12
$70,000
$23,000
Breast
$1,000
$500
$1,500

57. Operational Milestones Since OCR Implementation
Implementation of Oncology Case Rate Program
May program implemented for Sacramento practice
Jan program implemented for East Bay practice
Operational Milestones - annual enhancements of program for more efficient, effective & clinically appropriate system
Clinical proof of concept
Creation & automation of 835/ERA files for auto-posting of OCR program claims
Successful configuration of system rules
OCR claims module built & functional
Improvements in annual calibration system
Accurate & timely case rate payments
Efficient contracting updates & amendments
Automation of 50% of payment audits
QMP pre-payments
Clinical dashboards
Financial yield reports
QNXT Customization – in development
**Confidential**

58. Analytics & Reporting: Financial
Financial Dashboards - measures yield between OCR & standard fee-for-service payment methodologies

59. Analytics & Reporting: Clinical
Cohort Monitoring – tracks patient’s progression in the 3 year program
Stop Loss Threshold: $74,000
Cumulative 3-Year Case Rate: $35,796
Summary
Over Stop Loss Threshold
Between Stop Loss Threshold and Cumulative 3-Year Case Rate
Below Cumulative 3-Year Case Rate
Total
# of
Patients 10 12 68 90
% to Total # of Patients
11%
13%
76%
100%

60. Clinical Quality of Care
OCR Performance
ASCO = American Society of Clinical Oncology

62. Utilization Measure
Inpatient Bed Days

63. Overall Survival Results
All 4 Cancer Cohorts (N=274)
{Esophageal, Pancreas, Lung, Stomach}
OCR (N=128) vs. Control (N=146)
p = 0.05
Survival Probability
Survival Time (days)
Day 0 = first day of chemotherapy

64. Trends in Oncology PMPM Network vs. Sacramento OCR

65. Summary
OCR practices demonstrated year-over-year improvements in performance on ASCO clinical quality measures.
OCR practices out-performed standard FFS model in satisfaction and utilization metrics year-over- year.
OCR practices’ overall survival is non-inferior to the overall survival under a standard FFS model.
OCR practices continue to bend the cost curve over 3.5 years of program experience.