Oncology Patient-Centered Medical Home®

Business Case for Quality

Value Based Hematology and Oncology Care

John D. Sprandio, M.D., FACP Consultants in Medical Oncology & Hematology, P.C.

Oncology Management Services, LLC.

Philadelphia, PA

Agenda

• Rocket Science, Physician role, PCMH, Cancer• Performance Measurement• Oncology PCMH Model• Results• Replication• Stakeholder Perspective• Conclusion – it’s not just about Cancer

Rocket SciencePhysician’s Central RolePrimary PCMHFocus on Cancer Care

What’s Wrong with the US Health Care Delivery System?

Continuum of health care scienceBasic science – unravels mysteriesTranslational research – develop new treatmentsPolicy analysts – measure outcomesFundamental Question: How is care best delivered?

Dartmouth Center for Health Care Delivery Science

“The real rocket science now in health care is cost and quality.”

Dr. Jim Yong Kim

US Health Care

Focus on Cost: 2012 health care costs $ 2.8 trillion

Taken alone = the worlds 5th largest economy

We outspend the rest of industrialized world90% on rescue, 10% on chronic care verses 50/50

Targeting waste due to failures in:Delivery PricingCoordination Administrative burdenOverutilization Fraud

Focus on Quality: Legislation, Regulation, Enforcement, Policy Development, Market Demands

Doing Well by Doing Good:Improving the Business Case for Quality

Gosfiled, Reinertsen, et al. 2003

Physician engagement is essential in driving quality

Centrality of doctor-patient relationship:

• Most personal & critical interaction that defines healthcareExplanation, prediction, plan of care

• Physicians have a broadest scope of professional jurisdictionDrive the provision of all goods and services

• Patient experience based on one-on-one relationship• Physicians are the patient portal to the rest of the system

Referrals, education, interpretation of insurance benefits

Doing Well by Doing Good:Improving the Business Case for Quality

Gosfiled, Reinertsen, et al. 2003

Barriers to quality = physician “time stealers”Incentives, EMR, work-flow, decision support,

niche competitors, documentation & coordination systems, outcome targets, real-time performance measurement, lack of defined PC team based model

Physician work environment redesign StandardizeSimplifyMake clinically relevantEngage patientsFix accountability at the locus of control

Primary Care Focused Case for Quality & Value

Patient Centered Primary Care Collaborative

• 40 year old concept: ACP, AAFP, AAP, AOAPartnership with personal physician, coordinating/integrating/documenting care, promotion of quality & safety, enhanced access, whole person orientation, reduced acute events, reduced utilization, and improved outcomes

• NCQA emerged as one standard setting entity9 Standards3 levels of recognition

• Improved Value reported 2010 and 2012 (Grundy, et al)

Reduced costImproved clinical outcomesImproved patient and provider satisfaction

Era of Health Care ReformTransitioning from Volume to Value

Value = quality/costEnhance Quality by Increasing reliability of

delivery • Focus on execution (processes) of care delivery• Incorporation of High Reliability Principles

Control Cost by Reducing unnecessary utilization• Unnecessary utilization = waste• Failures of delivery, coordination, overtreatment

Demonstration of resultsData transparency, accountability, rapid learning

Focus on Cancer Care

• Microcosm of the US health care systemHigh technologyExpensive new drugsFragmented care

• 1.6 million Americans diagnosed with cancer annually

• Direct costs exceeded $126B in 2010• 0.69% of Commercially insured population• 11-12% of Commercial health care spend• Medicare responsible for > 50% of patients• Fastest growing cost area in medicine

Focus on Cancer Care

• Foundation of medical home and accountable care organizations has been primary care oriented

• Complex care outside the scope of primary care requires delegation to specialists (cancer, nephrology, etc.)

• How does the Primary PCMH or ACOs manage cancer costs if the patient is transferred to oncology?

• Oncology Patient-Centered Medical Home® (OPCMH) model has generated broad interest following recognition by NCQA in 2010

• Oncology PCMH projected to reduce cancer spend

Era of Cancer Care Reform Provider Accountability

“Only those giving the care can improve it”

Failure to control cost (waste, site of care) • Diminishes Value• Results in further funding cuts • Unintended clinical consequences for the most vulnerable• Reduced access, increased co-pays, reduced compliance

Standardization of delivery = waste reduction• Chemotherapy guidelines & pathways• Care delivery beyond chemotherapy selection• Requires practice transformation

Improving the Business Case for Quality

CMOH 2003-2013

Principles of re-designing cancer care delivery:

• Standardize/Streamline (variation in process of care)

• Simplify payment and administrative systems

• Minimize clinically irrelevant physician activity (Make complex decisions & maintain personal relationships)

• PCMH (engage, educate, access, coordination)

• Accountability at physician-patient locus (care team)

• Ongoing data driven process improvement

CMOH: 2009 – 2013

Making a Business Case for Quality• Focus on demand to improve quality and value• Led to development of OPCMH model• NCQA PCMH recognition & QOPI certification• Opportunity to lead positive change

Prepare for future payment models • Episode based, bundles, budgeted payment system

Prepare for future organizational structures• ACO, Hospital System/Payer hybrids, independent

practices, large single TIN networks, Clinically Integrated Networks, etc

Lessons from Medicare Demonstration Projects

CBO Issue Brief January 2012

6 Disease Management & Care Coordination

DemonstrationsGoal: Improve the quality of care for costly, chronic illnessesIn nearly all 34 programs spending was unchanged or increasedAll had 3rd party care management vendors involvedNumber of programs focusing on cancer care – none

4 Value-Based Payment DemonstrationsGoal: Improve quality and efficiency via financial incentives1/4 bundled payment programs resulted in 10% Medicare savingsSuccessful program operated at a lossNumber of programs focusing on cancer care – none

Take Home Message

Changes in payment & delivery systems are necessaryTimely data on use of care (potentially avoidable complications)Focus on transitions of care (Hospital discharge; primary to specialist)Physician-led team-based care (physician, nursing, navigators)Integrate management systems (minimize vendors)Target high-risk patients – predictive modelingRigorous design, concrete answers facilitates rapid learning cycle

Potential for successful re-designing care delivery in oncology

Physician-lead Care Management Team + Patient engagementPromotion of Physician Accountability at the point of deliveryTimely data driving a rapid learning cycle

Lessons from Medicare Demonstration Projects

CBO Issue Brief January 2012

Performance Measurement

The Four Habits of High-Value Health Care Organizations

Everyone believes they are delivering “high quality, highly reliable care”

• Specification and Planning

• Micro-system design

• Measurement and oversight

• Commitment to ongoing process improvement

Richard Bohmer, M.B.,Ch.B. NEJM 12/1/11

Internal Perception

40 50 60 70 80 90 1000

102030405060708090

100

Measured Reality

20 30 40 50 60 70 80 90 1000

102030405060708090

100

“Eminence Based Medicine”

Providing sub-optimal medical care with increasing confidence over an impressive number of years.

~British Medical Journal, Vol. 1 Sept 2001

© Kaufman Strategic Advisors, LLC

Strategic Goal

60 65 70 75 80 85 90 95 1000

102030405060708090

100

How can a physician-led care team reliably deliver cancer care?

Critical Provider Solutions

• Standardized process of care and data collection

• Presentation of consumable data, decision support – with each patient interaction

• Documentation tools to relieve the burden on a physician’s ability to execute care consistently

• Standardized communication

• Real time performance data

IRIS Software SuitePhysician-Centric Software

Enabling Patient-Centered Care• Clinical Decision Support System (CDSS)

– Work-flow integrated with delivery, documentation & MU – Speech-recognition integrated into work-flow– Immediate document completion and auto-dissemination

• Physician performance reports• Physician document and lab management review• Longitudinal performance status & NCI graded symptom

tracking • Triage outcomes & Unscheduled visit tracking• Personalized Patient Assessment and Verification Tool• Enhanced Patient Queuing/tracking program• Individual patient test result and appointment tracking • Screening and Immunization prompts • Portal access for patients and referring physicians• Palliative and End-of-Life Care Management prompts• Enables PCMH-N functionality

Quality, Service & Delivery Parameters

• ASCO - QOPI standards• NCCN Guidelines• American College of Surgeons• NQF, NCPF, NCCS, ONS• CMS - PQRS, e-Rx• NCQA – PPC-PCMHTM

• OPCMH – services• Institute of Medicine

– 1999 Ensuring Quality Cancer Care– 2001 Improving Palliative Care for Cancer– 2006 From Cancer Patient to Cancer Survivor: Lost in Transition– 2009 Assessing & Improving Value in Cancer Care– 2012 Best Care at Lower Cost

Oncology PCMH Model

Oncology Patient-Centered Medical Home® Model

Re-engineered Process of Care & Coordination • Ownership of all aspects of cancer care delivery• Focus on patient needs and evidence-based care• Reduction in unnecessary variation & resource utilization• Enhanced communication with PC PCMH & Specialists• Real-time physician/practice performance measurement• Continuous process improvement

• Encourages Clinical Integration between practices

Oncology Patient-Centered Medical Home® Based on NCQA PPC-PCMHTM

NCQA Standards drive Quality, Service & Utilization

• Enhanced Access & Continuity• Identify and Manage Populations• Plan and Manage Care• Self-care Support & Community Resources• Track and Coordinate Care• Measure and Improve Performance

Process MeasurementRapid Learning Cycle

• Function of mutually reinforcing care-teamInterdependent roles, responsibilities, and hand-offs

• Merging Work-Flow & Clinical Decisions • Guidelines, staging, screening, prevention• Triage & Symptom Management algorithms• Communication/Documentation turn around• Patient Navigating/tracking tests & referrals• Performance Status & Palliative Care tracking• End of life care/promoting shared decisions• Patient & Physician portal utilization• Management of at risk populations

Patient & Payer Centered

Outcome Measures

Patient Experience• AHRQ CAHPS: Consumer Assessment of Healthcare

Providers and Systems

Outcomes• Staging compliance• Chemotherapy guideline adherence• Emergency Room evaluations• Hospital admissions / length of stay• Outpatient visit reduction• End of Life Care parameters• Diagnostics: imaging & laboratory

Results

NCQA PCMH & The Four Habits of High-Value Health Care Organizations

“The ability to disseminate and deliver high value clinical

innovation is based on similar, portable habits of care management … implemented simultaneously” Richard Bohmer, M.B.,Ch.B. NEJM 12/1/11

• Specification and Planning – Merging operational and clinical decisions with documentation

• Micro-system design– Matching subpopulations and pathways, triage algorithms

• Measurement and oversight– Targeting internal operational issues – drive outcomes

• Commitment to ongoing process improvement– Insights for better outcomes fuels modification of Specification and Planning

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

USON/Milliman: Approximately 2 emergency room visits 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

Guideline & Pathway Adherence

Chemotherapy care plans are NCCN compliantDeviation requires customization (controlled)Physician selects care plan within EMR• Selection shared with billing and nursing staff

NCCN ComplianceAdjuvant and first line metastatic • Adherence > 95% 2007 – 2010 (practice)• Individual physician performance followed

Pathway ComplianceSmall number of patients > 80%

OPCMH End-of-Life Care Collaborative Dartmouth OPCMHTM QOPI Measure

Death in hospital % X X PH numerator; denominator ? Practice*

Hospital admissions, last 30 days, % X X PH numerator; denominator ?

Practice*

ICU admissions, last 30 days, % X X PH numerator; denominator ? Practice*

ICU Days, last 30 days X X PH numerator; denominator ? Practice*

ChemoRx, last 30 days X X X PH numerator; denominator ? Practice*

Hospice, last 30 days, % X X PH numerator; denominator ? Practice*

Hospice days, last 30 days X X PH numerator; denominator ? Practice*

Hospice within 7 days of death, % X X X PH numerator; denominator ? Practice*

Hospice enrollment, % X X PH numerator; denominator ? Practice*

ACP discussion with metastatic disease X X PH numerator and

denominator

Advanced care plan documented, % X Practice

ECOG performance status documented at each visit X Practice

OPCMH End of Life Care• Performance Status Driven

Influences ongoing treatment decisionsStandardized assessment & longitudinal tracking of PS Impact of disease & therapy on abilities, QOLAuditing for PS decline (ECOG 3)

Ongoing Discussion of Goals of TherapyDocumentation at onset of stage IV diseaseDocumentation of ongoing discussion with decline in PS, change in therapyGoal: Promote shared decision-making

End of Life Care Data

• Hospice Average Length of Stay:2009: 26 days 2010: 32 days2011: 35 days

• Place at time of death: 70% home 2010

74% home 2011

• ER visits & hospital admissions last 30 days of life:– 2010: 39.3% total practice Admissions– 2011: 36.4% total practice Admissions – 2010: 23.8% total practice ER visits– 2011: 20.1% total practice ER visits

34% increase

Oncology PCMH Impact on Cost of Cancer Care

Projected % Reduction in Cancer Care Cost

1-3 Chemotherapy pathways program4-6.3 Inpatient hospitalizations (5-25% reduction).6-1.1 ER evaluations (20-40%).1-.4 Diagnostics.9-1.9 End-of-life care coordination

Total 6.6 – 12.7 % reductionAnnual cancer “spend” $125B = $8-16B savings

Adapted from international consultants evaluation of OPCMHTM application to cancer care

Replication

Replication of the ModelFour Key Steps

Specialty societies define quality parameters• ASCO, ACOS, NCCN, COA, NQF, NCPF

NCQA Specialty Practice Recognition Program• Application of PCMH principles to specialties• Specialty Practice standards March 2013

Payer engagement and support• Regional and national payers

Phases of construction of PC-SP• Payer Incentives & Practice Deliverables defined

NCQA PC-SPR Transformation vs other Quality Improvement models

NCQA Standards are based on:Service, quality, utilization, meaningful use

• Standardized processes across practice• Re-defined roles - supporting a physician-

led team• Promotion of physician efficiency &

accountability• Applicable to Oncology, Nephrology,

Cardiology, Rheumatology

Level of Oncology Accountability Models for Payment of cancer care

FFS Pathways OPCMH Bundled or Episode Payment

Oncology Patient-Centered Medical Home® Value Proposition

• OPCMH – clinical & business methodologies– Data driven practice/patient care efficiencies– Community and hospital-based practices

• OPCMH - organizational construct– Oncology “plug-in” to PCMH as a PCMH-N– Establishes care management accountability– Communication that bridges specialists and PCMH

• OPCMH – as PCMH bridge– Aligns oncologists for ACO, Clinical Integration, etc– Platform for pricing bundles, episodes, etc or

episode of care payment

Stakeholder Perspective

Patients & Payers Want Reliable Patient-Centered Services

• Personal relationship with a physician– Explanation, Prediction, Plan of intervention

• “On demand” access to care & information• Total coordination of all aspects of care• Communication among all providers of care • Best possible outcomes– Improvement & preservation of quality of life– Fewer complications, ER, hospital admissions, visits• Fewer co-pay related events

– Rational care at the end of life

Summary

• Foundation of PCMH and ACOs are primary care oriented

• Costly care exists outside the scope of primary care• Primary care delegates management of complex care

(cancer, nephrology, etc) to specialists• The specialty community has the capacity to

dramatically improve care and reduce costs• This requires practices to transform the way they

deliver care, which requires stakeholder collaboration • Payers need to promote physician driven efforts to

enhance value & continuously improve care delivery

Questions

For more information about Oncology Patient Centered Medical Home:

John Sprandio jsprandio@cmoh.org

Susan Tofani STofani@oms-support.com www.OPCMH.com