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Transcript of Not for redistribution. © 2014 Oncology Management Services, Consultants in Medical Oncology &...
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Will Value-Based Payment Systems Foster Better
Survivorship Care
Oncology PCMHJohn D. Sprandio, MD, FACPChief Physician,Consultants in Medical Oncology and Hematology (CMOH), PCChairman, Oncology Management Services, Inc
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Meeting Survivorship Needs
• Practice transformation, care delivery models• Associated payment reforms• Are care models and payment methods re-
aligning patient and provider behavior and driving patient-centered care?
• What’s missing?• When is it coming?
1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results
Non-risk adjusted practice dataPreliminary risk-adjusted payer data
4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update
Alternate payment models Scalability of Oncology PCMH
model
Joint Principles of PCMH
Medical Neighborhood
Value in Cancer Care
Enhancing Value in Cancer Care
Oncology PCMH Quality & Value Driver DiagramOncology PCMH Quality & Value Driver Diagram
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Primary Driver Care Team Environment Delivery Standards
Services
Primary Driver Care Team Environment Delivery Standards
Services
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
National Committee for Quality Assurance
PCSP Recognition PCOC standards
National Committee for Quality Assurance
PCSP Recognition PCOC standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards NCCN
Treatment Guidelines Survivorship Guidelines
NCCN Treatment Guidelines
Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Patient Advocacy Data NCCS, CSC, ACS
Patient Advocacy Data NCCS, CSC, ACS
American College of Physicians PCMH-NAmerican College of Physicians PCMH-N
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Symptom Management
On Demand Access/Visits Performance data collection Track success of Palliation
Symptom Management On Demand Access/Visits
Performance data collection Track success of Palliation
Survivorship Care Standardized Care Plans
Coordination Agreements
Survivorship Care Standardized Care Plans
Coordination Agreements
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Data Driven ImprovementData Driven Improvement
Multi-disciplinary Guideline
Concordance
Multi-disciplinary Guideline
Concordance
Palliation Symptom Management Focus on Performance
Status (PS)
Palliation Symptom Management Focus on Performance
Status (PS)
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Patient & Family Experience of Care
Patient & Family Experience of Care
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
Survivorship Care Standardized
Primary PCMH
Survivorship Care Standardized
Primary PCMH
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging ©2014 Oncology Management Services, Ltd.
Payer Based Episode and “OMH” Programs
CMS & Commercial
Oncology PCMH Quality & Value Driver DiagramOncology PCMH Quality & Value Driver Diagram
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Primary Driver Care Team Environment Delivery Standards
Services
Primary Driver Care Team Environment Delivery Standards
Services
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
National Committee for Quality Assurance
PCSP Recognition PCOC standards
National Committee for Quality Assurance
PCSP Recognition PCOC standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards NCCN
Treatment Guidelines Survivorship Guidelines
NCCN Treatment Guidelines
Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Patient Advocacy Data NCCS, CSC, ACS
Patient Advocacy Data NCCS, CSC, ACS
American College of Physicians PCMH-NAmerican College of Physicians PCMH-N
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Symptom Management
On Demand Access/Visits Performance data collection Track success of Palliation
Symptom Management On Demand Access/Visits
Performance data collection Track success of Palliation
Survivorship Care Standardized Care Plans
Coordination Agreements
Survivorship Care Standardized Care Plans
Coordination Agreements
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Data Driven ImprovementData Driven Improvement
Multi-disciplinary Guideline
Concordance
Multi-disciplinary Guideline
Concordance
Palliation Symptom Management Focus on Performance
Status (PS)
Palliation Symptom Management Focus on Performance
Status (PS)
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Patient & Family Experience of Care
Patient & Family Experience of Care
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
Survivorship Care Standardized
Primary PCMH
Survivorship Care Standardized
Primary PCMH
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Payer Based Episode and “OMH” Programs
CMS & Commercial
©2014 Oncology Management Services, Ltd.
Oncology PCMH Quality & Value Driver DiagramOncology PCMH Quality & Value Driver Diagram
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Primary Driver Care Team Environment Delivery Standards
Services
Primary Driver Care Team Environment Delivery Standards
Services
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
National Committee for Quality Assurance
PCSP Recognition PCOC standards
National Committee for Quality Assurance
PCSP Recognition PCOC standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards NCCN
Treatment Guidelines Survivorship Guidelines
NCCN Treatment Guidelines
Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Patient Advocacy Data NCCS, CSC, ACS
Patient Advocacy Data NCCS, CSC, ACS
American College of Physicians PCMH-NAmerican College of Physicians PCMH-N
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Symptom Management
On Demand Access/Visits Performance data collection Track success of Palliation
Symptom Management On Demand Access/Visits
Performance data collection Track success of Palliation
Survivorship Care Standardized Care Plans
Coordination Agreements
Survivorship Care Standardized Care Plans
Coordination Agreements
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Data Driven ImprovementData Driven Improvement
Multi-disciplinary Guideline
Concordance
Multi-disciplinary Guideline
Concordance
Palliation Symptom Management Focus on Performance
Status (PS)
Palliation Symptom Management Focus on Performance
Status (PS)
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Patient & Family Experience of Care
Patient & Family Experience of Care
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
Survivorship Care Standardized
Primary PCMH
Survivorship Care Standardized
Primary PCMH
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Payer Based Episode and “OMH” Programs
CMS & Commercial
©2014 Oncology Management Services, Ltd.
Oncology PCMH Quality & Value Driver DiagramOncology PCMH Quality & Value Driver Diagram
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Primary Driver Care Team Environment Delivery Standards
Services
Primary Driver Care Team Environment Delivery Standards
Services
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
National Committee for Quality Assurance
PCSP Recognition PCOC standards
National Committee for Quality Assurance
PCSP Recognition PCOC standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards NCCN
Treatment Guidelines Survivorship Guidelines
NCCN Treatment Guidelines
Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Patient Advocacy Data NCCS, CSC, ACS
Patient Advocacy Data NCCS, CSC, ACS
American College of Physicians PCMH-NAmerican College of Physicians PCMH-N
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Symptom Management
On Demand Access/Visits Performance data collection Track success of Palliation
Symptom Management On Demand Access/Visits
Performance data collection Track success of Palliation
Survivorship Care Standardized Care Plans
Coordination Agreements
Survivorship Care Standardized Care Plans
Coordination Agreements
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Data Driven ImprovementData Driven Improvement
Multi-disciplinary Guideline
Concordance
Multi-disciplinary Guideline
Concordance
Palliation Symptom Management Focus on Performance
Status (PS)
Palliation Symptom Management Focus on Performance
Status (PS)
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Patient & Family Experience of Care
Patient & Family Experience of Care
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
Survivorship Care Standardized
Primary PCMH
Survivorship Care Standardized
Primary PCMH
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Payer Based Episode and “OMH” Programs
CMS & Commercial
©2014 Oncology Management Services, Ltd.
©2014 Oncology Management Services, Ltd.
How We Equipped Our Practice for the Oncology Patient-Centered Medical Home®
1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results
Non-risk adjusted practice dataPreliminary risk-adjusted payer data
4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update
Alternate payment models Scalability of Oncology PCMH
model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Go to nearest ER2.15%
Chemo Suite Intervention0.21%
Office visit today3.93%
Office visit tomorrow3.60%
Referred to Pri-mary/
Special-ist
5.30%
Pt sent for Ra-
dio-graphic Study2.01%
Manage Symptom(s) at home82.80%
Outcome of Clinical Nurse Triage Phone Calls in 2014n = 4832 clinical phone calls
7.53% of patients were seen in the of-fice within 24 hours of call
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
2.600 2.567
2.067
1.604
1.2731.119
0.9100.818
0.7030.550 0.541
0.000
0.500
1.000
1.500
2.000
2.500
3.000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Year
Average emergency room (ER) Evaluations per chemotherapy patient per year (APCPPY)
for the CMOH patient population , 2004-2014.
ER
Eva
lua
tio
ns p
er
ch
em
oth
era
py p
ati
en
t p
er
USON/Milliman: Approximately 2 emergency room visits per chemotherapy patient per year
(14 million commercially insured; 104,473 cancer patients)Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
© 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
2007 2008 2009 2010 2011 2012 2013 20140.000
0.200
0.400
0.600
0.800
1.000
1.200
1.0801.055
0.876
0.605
0.528
0.694
0.562
0.499
Average Admissions per Chemotherapy Patient Per Year (APCPPY) for CMOH patient population, 2007-2014
APCP
PY
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
Measure Line(s) of Business
Hospitalizations per chemotherapy treatment (within 60 days) Commercial and Medicare Advantage
ER Visits per chemotherapy treatment (within 60 days) Commercial and Medicare Advantage
Hospice days in last 60 days of life per chemotherapy patient Medicare Advantage Only
Hospitalizations in last 30 days of life per chemotherapy patient Medicare Advantage Only
Chemotherapy treatment in last 30 days of life per chemotherapy patient Medicare Advantage Only
Payer Risk-Adjusted Oncology PCMH Measures
Initial 7 months of contract (risk adjusted)Commercial Medicare Advantage
CMOH Rate 0.024 0.025
Plan Benchmark (Market basket based on CMOH’s Top 15 Dx codes)
0.036 0.067
Admissions Saved per chemotherapy treatment 0.012 0.041
CMOH % Reduction in Admissions vs Network 33% 61%
Average Cost per Admission $ $
Total Savings $ $
xx% Shared Savings $ $
Hospitalizations per chemotherapy treatment (within 60 days)
Initial 7 months of contractMedicare Advantage
CMOH Rate 0.000
Plan Benchmark 0.447
Admissions Saved per patient 0.447
Total admissions saved xx.x(0.447 x xx expired pts)
Average Cost per Admission $
Total Savings $
xx% Shared Savings $
Hospitalizations in last 30 days of life per chemotherapy patient
Chemotherapy treatments in last 30 days of life per patient
Initial 7 months of contractMedicare Advantage
CMOH Rate 0.000
Plan Benchmark 0.458
Chemotherapy treatments saved/patient 0.458
Total chemotherapy treatments saved xx.x(0.458 x expired patients)
Average Cost of chemotherapy treatment $
Total Savings $
xx% Shared Savings $
Hospice days in Last 60 days of life (Medicare Advantage only)Initial 7 months of contract
15.25 •CMOH
13.84 •Plan Benchmark
Yes •10% Better than Plan
1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results
Non-risk adjusted practice dataPreliminary risk-adjusted payer data
4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update
Alternate payment models Scalability of Oncology PCMH
model
Provider Ability and Accountability Payment Reform for Cancer Care
30% of traditional Medicare tied to PCMH, ACO, Budgeted Payments by 2016 – 50% by 2018 90% of traditional Medicare will contain Quality & Value parameters by end of 2018
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Payment Reform
UnitedHealthcare: Lee Newcomer, Episode and Bundled programsPCORI funded Oncology PCMH Project (SEPA)
NCQA, OMS, ASCO, RAND, NCCS, IBCCOME HOME PROJECT: OMH, CMMI, IOBS Horizon Blue Cross, RCCA: Medical Oncology BundlesOncology Bundled Payment Consortium - OCM
CAP, CMS, CMMI, multiple payersCMS Oncology Payment Reform TEP - OCM
MITRE, Brookings, RAND, CMS, CMMIASCO and COA Payment Reform InitiativesOMS Alternate Payment Methods (Pennsylvania)
IBC, Keystone First, Capital Blue Cross
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
CMS Oncology Care Model (OCM)
Combined features of CMS Oncology Payment Reform TEP + CAP Bundled Payment Consortium
Medical oncology treatment episodes - broadly applied PCMH Practice Transformation
• Patient Navigators• Enhanced Coordination• Structured Care Management Plan (IOM)• 24/7 access to clinician with records• Adherence to nationally recognized treatment guidelines• Oncology specific EHR, stage 2 MU by end of year three• Data driven quality improvement program
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
CMS Oncology Care Model (OCM)
Performance Metrics – reported quarterlyDriven by Care Team execution of PCMH processes
• ER visits/Hospital admissions (episode + 6 months & EOL)• CAHPS (oncology version)• Comprehensive health assessment, including PS • Psychological screening (once/episode)• Palliative care (concurrently or via formal consultation)• Transition coordination and follow-up testing/OP visits• Medication reconciliation • Pain management• Hospice Utilization• Resource Utilization (drugs, radiation therapy, imaging, laboratory)• Results of data driven quality improvement efforts
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Standardized Engagement & Orientation• Patient Navigation
• Shared Decision-MakingExplanation – specific TNM & molecular stagingPrediction – natural history, impact on performance status Treatment options – consensus based guidelinesFinancial counseling – patient OOP expensesPatient Preferences – life goals, family responsibilities, hobbies Plan of Care – discussed and mutually agreed uponGoals of therapy defined, modified – curative or palliative Written or electronic plan shared with patient/stakeholders
• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management
• Survivorship Care • Treatment team is the survivorship care team• “Care Management Plan” transitions to “Survivorship Care Plan”• Care plan templates for site and stage (ASCO)• Treatment and clinical summary (toxicities and co-morbidities)• Genetic history, updating family history • Documentation and management of residual symptoms• Surveillance, screening, risk reduction, health promotion• Community resource utilization • Coordination agreements with primary care team (ACP PCMH-N)
Responsibility matrix defined – primary, medical, radiation and surgical oncology • Goals of therapy
1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results
Non-risk adjusted practice dataPreliminary risk-adjusted payer data
4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update
Alternate payment models Scalability of Oncology PCMH
model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA
• IRISTM App development• IRIS: integrates processes, work-flow, data collection, data
presentation, response to data, documentation, communication and performance feedback to providers
• Aggregates, analyzes, re-organizes clinical and performance data in a consumable way that fits the work-flow of cancer care
• 90% of data collected and presented prior to physician entering the exam room – focus: shared complex decision-making
• Middleware, FHIR enabled, EMR agnostic app development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA• IRISTM Development
• Scalability of an Oncology PCMH ModelPayment reform and technology
• Payer and provider collaboration• Technology - not just about data – it is a human endeavor
Integration of “big data” of obvious importance “Small data” involved in shared decision-making is equally important
• Technology supporting the patient-physician interactionIs a template for practice transformationDefines care-team roles, efficient work flow, fixes accountabilityEnhances flow of information in complex careCentral to reduction in unnecessary resource utilization
Thank youContact Information
John D. [email protected]
Visit us at www.opcmh.com to register for OMS’ Healthcare Delivery Seminar
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
• Appendix
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
Consistent approach by the care team• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Define role of nurse and patient navigators, physicians, etc• Modes of enhanced access & coordination defined• Financial counseling – details of insurance coverage • Patient reporting & practice responsibilities• Practice as “Point of First Triage” • Symptom and disease management strategies (nurse triage)• Patient Portal education
• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation
• Patient Navigation• Lay Navigators• Scheduling of all imaging, laboratory testing • Precertification of necessary imaging• Scheduling all external provider appointments
Oncologic and non-oncologic
• Tracking test results and consultation reports to completion Re-scheduling when necessary
• Interface/scanning of reports • Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Standardized Engagement & Orientation• Patient Navigation
• Shared Decision-MakingExplanation – specific TNM & molecular stagingPrediction – natural history, impact on performance status Treatment options – consensus based guidelinesFinancial counseling – patient OOP expensesPatient Preferences – life goals, family responsibilities, hobbies Plan of Care – discussed and mutually agreed uponGoals of therapy defined – curative or palliative Written or electronic plan shared with patient/stakeholders
• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making
• Execution of CareStandardized outpatient processes and work flowPatient self assessment questionnaire (PSAQ)Data collection and presentation drives decisionsAdherence to multidisciplinary and chemotherapy guidelinesNavigation, communication & coordination of all aspects of careProvider team accessibilityPerformance metrics monitored
• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care
• Care coordinationMultidisciplinary input – Primary, Surgery, Radiation, Medical OncologyTimeline of intervention discussed and scheduledStandardized communication among primary care & oncology teamsCoordination of care between oncologist, primary and other specialistsCoordination of care arrangements define responsibilities (PCMH-N)Transitions of care OP to ER or Admission, admission to OP
• Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination
• Symptom management – during and between OP visitsStandardized symptom data collection, grading & documentationAuto-populated fields in documentation driving physician
response Longitudinal view of success of symptom managementDocumentation of specific recommendations shared with patientTelephone triage 24/7 - standardized algorithms Documentation of type and disposition of every call
• Survivorship Care• Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management
• Survivorship Care • Treatment team is the survivorship care team• “Care Management Plan” transitions to “Survivorship Care Plan”• Care plan templates for site and stage (ASCO)• Treatment and clinical summary (toxicities and co-morbidities)• Genetic history, updating family history • Documentation and management of residual symptoms• Surveillance activity and screening• Community resource utilization • Coordination agreements with primary care team (ACP PCMH-N)
Responsibility matrix defined – primary, medical, radiation and surgical oncology • Goals of therapy
Not for redistribution. © 2015 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Standardized Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care
• Goals of therapyPerformance Status driven decision making in non-curative setting
Standardized PS measurementDocumentation of ongoing goals dialogue based on PS changes
Goals of therapy updated via replay of: Explanation, Prediction, Options, Patient Preference, Plan of
Care Hospice utilization monitored
Chemotherapy Guidelines
Oncology PCMHConcurrent Delivery of Palliative Care
Oncology PCMHEnd-of-Life Care
Oncology PCMHSurvivorship Care
Oncology PCMHTransitions of Care Responsibility
1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results
Non-risk adjusted practice dataPreliminary risk-adjusted payer data
4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update
Alternate payment models Scalability of Oncology PCMH
model
Quality and Cost Are Completely Intertwined
1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results
Non-risk adjusted practice dataPreliminary risk-adjusted payer data
4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update
Alternate payment models Scalability of Oncology PCMH
model
Projected % Reduction in Total Cancer Care Cost
1-3 Chemotherapy pathways program4-6.3 Inpatient hospitalizations (5-25% reduction)0.6-1.1 ER evaluations (20-40%)0.1-.4 Diagnostics0.9-1.9 End-of-life care coordination
Total 6.6 – 12.7 % reductionAnnual cancer “spend” $125B = $8-16B savings
Adapted from international consultants assessment of OPCMH® cancer care model
OPCMH® Impact on Practice
1) Quality and Value in healthcare2) Oncology PCMH model3) Demonstration of results
Non-risk adjusted practice dataPreliminary risk-adjusted payer data
4) Benefits to Payers, Patients and Providers5) Evolution of Oncology Payment Models6) OMS Update
Alternate payment models Scalability of Oncology PCMH
model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA
• IRISTM App development• IRIS: integrates processes, work-flow, data collection, data
presentation, response to data, documentation, communication and performance feedback to providers
• Aggregates, analyzes, re-organizes clinical and performance data in a consumable way that fits the work-flow of cancer care
• 90% of data collected and presented prior to physician entering the exam room – focus: shared complex decision-making
• Middleware, FHIR enabled, EMR agnostic app development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA• IRISTM Development
• Scalability of an Oncology PCMH ModelPayment reform and technology
• Payer and provider collaboration• Technology - not just about data – it is a human endeavor
Integration of “big data” of obvious importance “Small data” involved in shared decision-making is equally important
• Technology supporting the patient-physician interactionIs a template for practice transformationDefines care-team roles, efficient work flow, fixes accountabilityEnhances flow of information in complex careCentral to reduction in unnecessary resource utilization
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
Oncology PCMH program transformation services• Local Contracting• NCQA Collaboration• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capitol Blue Cross Project• Regional Value-Based Oncology IPA• IRIS Development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• Two active Alternative Payment Arrangements (CMOH)
(1) 4.5 years durationEnhanced E&M, infusion service payments relative to all
patients(2) 15 months duration
Shared savings relative to all actively treated patients – ER visits, Admissions, and EOL related ER, admissions, hospice utilization
Both contracts benchmarked against the market(3) Failed contractual experiment (5% of 12% of CMOH patients)
• NCQA Collaboration• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting
• NCQA Collaboration • Patient Centered Specialty Practice (PCSP) standards
Extraction of Primary Care elements and featuresPrioritization of standards, features and elements for specialty care
• Draft development of Patient Centered Oncology Care (PCOC) Standards – refined in PCORI project in SEPA
• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• NCQA Collaboration
• CMS TEP & Bundled Payment Consortium (OCM)• CMS technical expert panel contribution
PCMH capabilities central to practice eligibility requirementsCMS Oncology Care Model 2016
• CAP Oncology Bundled Payment ConsortiumEpisode based payment model around Medical Oncology ServicesConsortium influenced OCM modelUHC MD Anderson Head & Neck Program (true bundle)
• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)
• PCORI Project, Southeastern PA• NCQA led, PCORI funded oncology PCMH project
NCQA, ASCO, OMS, RAND, IBC, Aetna, NCCSFive practices ranging from 4 to 44 physicians, 4 different EMRsPCOC standard under development (PCSP backbone)Reporting: Transformation, utilization and patient satisfactionProvider incentive: participation in Alternate Payment Arrangements
• Capital Blue Cross Project (East Central PA)• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA
• Capital Blue Cross Project (East Central PA)• Payer sponsored transformation support• Payment reform aligned with CMS OCM
Enhancement of E&M for all patients based on OMS confirmed practice PCMH capabilities and milestonesShared savings arrangement included Benchmark – the CBC network
• Five community based practices beginning 6/30/15• Regional Value-Based Oncology IPA• IRISTM Development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)
• Regional Value-Based Oncology IPA• Emergence of a large independent Primary Care Network
Seeking Value-Based specialty providers
• Active discussions with referral base, providers and payers• IRISTM Development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)
• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA
• IRISTM App development• IRIS: integrates processes, work-flow, data collection, data
presentation, response to data, documentation, communication and performance feedback to providers
• Aggregates, analyzes, re-organizes clinical and performance data in a consumable way that fits the work-flow of cancer care
• 90% of data collected and presented prior to physician entering the exam room – focus: shared complex decision-making
• Middleware, FHIR enabled, EMR agnostic app development• Scalability of an Oncology PCMH Model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Management Services (OMS)• Local Contracting• NCQA• CMS TEP & Bundled Payment Consortium (OCM)• PCORI Project Southeastern PA• Capital Blue Cross Project (East Central PA)• Regional Value Based Oncology IPA• IRISTM Development
• Scalability of an Oncology PCMH ModelPayment reform and technology
• Payer and provider collaboration• Technology - not just about data – it is a human endeavor
Integration of “big data” of obvious importance “Small data” involved in shared decision-making is equally important
• Technology supporting the patient-physician interactionIs a template for practice transformationDefines care-team roles, efficient work flow, fixes accountabilityEnhances flow of information in complex careCentral to reduction in unnecessary resource utilization