Evolving the Oncology Medical Home• Dr. Michael Kolodziej, National Medical Director,

Oncology Solutions, Aetna• Kathy Lokay, President and CEO, Via Oncology• Barry Russo, CEO, The Center for Cancer and Blood

Disorders• Maria Sipala, Director, Strategic Planning, National

Network Contracting, Aetna• Amy Supraner, Strategic Planning Manager, National

Network Contracting, Aetna• Dr. Ira Klein, National Medical Director, Clinical

Thought Leadership, Aetna

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We, too, can evolve further!

In the Beginning, a study: ↑ Adherence to EBM had ↓ cost with no negative impact on treatment efficacy

– Study: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting” (NSCLC)

– Published: Journal of Oncology Practice (American Society of Clinical Oncology Peer Reviewed Journal), 1/19/2010

No change in overall survival between the study groups

Source: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting”. Journal of Oncology Practice. January 2010. Volume 6. No.1. p 12-18

Significantly lowered cost in the case group vs. The control group

Purpose: Evaluate the cost effectiveness of evidence-based treatment pathways for NSCLC patients

Conclusion: Results of this study suggest that treating patients according to evidence-based guidelines is a cost-effective strategy for delivering care to those with NSCLC.

Overall survival by Pathway status.

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5

We All Derived a Similar Equation Regarding Cost and Efficacy in Cancer Care

V = Q

C

• Guideline Based Therapies

• Targeted Impact• Low Toxicities• Improved Survival• Improved QOL

• Best Supportive Care• Avoidance Hospital Days• Avoidance ED Visits• Site of Service Costs ↓• Medically Unnecessary

Care ↓ at EOL

Aetna Developed a Payer Strategy around this, and so did everyone else…..but not all the same

• Drive efficient use of evidence-based medicine– platform that provides content and workflows– integrate into the Aetna and provider systems – simplify the administrative processes for providers

• Avoid waste and misuse of medical services – better provider alignment

(e.g., Oncology Patient Centered Medical Home), – better network (narrow, tiered)– better decision support strategies

• Leverage and integrate the many current (and future) medical and pharmacy cancer-care initiatives

– seamless, end to end cancer experience for Aetna members and providers

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Who’s got Clinical Decision Support (CDS) available in the Marketplace?

Where Aetna has been with “pilots” in order to prove out theoretical concepts:

Can CDS tools alone, without other inducements beyond minimal workflow improvements, influence NCCN guideline compliance in all pop., no additional economic incentives?

Do Pathways tools (clinical decision support, or CDS) + oncology medical home resources make economic sense, contract in commercial pop.?

Will CDS tools and medical home resources and tight healthplan linkages and reporting improve value parameters in Medicare pop., blended contract?

Can CDS tools alone + altered drug fee schedules improve value parameters, pay for value contract, all pop.?

2010 2011 2012 2013

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TX Oncology pilot Cardinal/P4 pilot Eviti pilot TX Oncology pilot, #2

FFS payments to physicians

Total physician payment

All other payments

Current Model Proposed Model

Current Model Proposed Model

To

tal

ph

ys

icia

np

ay

me

nt

All o

the

rC

an

ce

r ca

reS

pe

nd

ing

e

lem

en

ts

FFS payments to physicians

Care coordination feeCase management payment

Payment for all other cancer carePayment for all other

cancer care

Waste and inefficiency Waste and inefficiency

The Goal is to Achieve Meaningful Payment Reform

The Brookings Institution, Washington, D.C.

Next Step: the Oncology Medical Home

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What’s Needed for Practices to meet the Aetna Criterion for OMH Contracting:

Market level conditions

Practice Volume

Oncology Medical Home Solution

Practice IT & other capabilities

40-50 Aetna Breast, Lung, Colorectal Cancer patients and $500-600K per year spend on them.

Must use Clinical decision support tool.

Perform enhanced triage, both telephonic and in-office

Nurse Navigator.

Can conduct and collate results of a patient satisfaction survey.

Can do PDCA style quality improvement program.

Membership in Market. Market buy-in. Is there a mandatory

CDS program in state? Is practice in ACO/PHO?

Infusion Suite in office (buy and bill model) vs. sending to outpatient infusion center.

Aetna Oncology Medical Home payment for oncology care means growth instead of shortfall

Sustainable Future

Performance

*Ultimately, this becomes

a better “reset”

baseline for episodes and/or bundles

Current Fee for Service

ModelInvest in

New processes

Shared Savings on

improvement from

baseline outcomes

Enhanced drug fee schedule

Changes in pre-cert

model alter FTE’s

S-codes for quality

processes that have meaningHIT Office

workflow efficiencies

*Diagram is illustrative and for discussion purposes only

Our goal is to create a sustainable business model designed around new sources of value that will be resilient through and post health care reform.

Growth

Future Base Model(s) Without Medical

Home-like contracts

Revenue Gap(e.g., private payer and

CMS induced)

Practice Demographics Market Benchmarks

Savings Calculations

Aetna Shared Savings Practice Shared Savings

Reconciliation: Practice, Market Level Benchmarks, Financials

The Future: Move Providers up the Value Chain with multiple support effortsVendor based programs introduce Clinical Pathways and Measure Adherence along with Quality Measures

More sophisticated Practices move from vendor based Clinical Pathways programs to Oncology Medical Homes (OMH)

Smaller Practices work with Education Oncology programs such as NJ ION program

Create episode and bundling methodology test with OMH, as well as deployed in ACO

Provider engagement Index

Low Touch High TouchSome Clinical Engagement

OMH deployed in 65% of markets and ACOs by 4Q15

More Clinical Engagement

High Clinical Engagement

Cardinal, New Century Health, Innovent