Achieving Value in Oncology: A 5000 to 50 Foot View

Blase N Polite, MD MPP Associate Professor of Medicine Deputy Section Chief for Clinical Operations Executive Medical Director for Cancer Accountable Care 2 Annals of Family Medicine 2012;10:156 4 The Forces For Change

• Public Payers – Medicare Oncology Care Model – MIPS-MACRA – APMs-MACRA – Medicaid Managed Care Organizations

• Private Payers – Oncology Medical Homes-Several Insurers-Aetna – United Health Care Episode Payment Pilot – WellPoint Cancer Quality Program

5 How To Achieve Value: Easy in Theory

• Use Pathways to evaluate appropriate use of therapies – Give Highest Value Therapy to Right Patient at Right Time – Avoid Low Value Therapies • Develop Mechanisms to Reduce Expensive Services – ER Visits – Inpatient Hospitalizations – Readmissions • Focus on End of Life Care

– Death in ICU or Hospital – Enrollment to Hospice – Hospice Length of Stay

6 7 Bridging the Gap

7

©2015 The Advisory Board Company • advisory.com Pharmacy: TargetingValue Supportive DrugBased Expenditure Opp Cost is a Fee For Service Profit Pegfilgrastim  Filgrastim Denosumab  Zolendronic Acid ortunities

Avg Avg Paymen Drug Paymen Drug 2014 2014 t Per Order t Per Order (Baseline) (Baseline) Drug Count Drug Count Order Order Denosumab $1,603 431 $690,893 Pegfilgrastim $3,295 640 $2,108,800 Zolendronic $237 270 $63,990 Filgrastim $421 321 $135,141 Acid Incremental $421 640 $269,440 Incremental Filgrastim Zolendronic $237 431 $102,147 Total Acid Potential $1,704,219 Total Savings Potential $524,756 Savings

Drug Average Cost Per Treatment (7 cycles) Rituximab $13,800 $9,600 Rituximab Hyaluronidase $23, 400 Potential Cost for 50 patients/year $480,000 Oncology Care Model-Key Features of the Model • 6 month episodes begin when chemo (IV or oral) administered/filled

• Multiple 6 months episodes allowed as long as patient receiving chemo

• Patient management fee of $160 paid monthly to practice throughout the 6 month episode

• Benchmark price derived from national data for each episode (using 2012-2015 data), risk adjusted, and adjusted for practice use of novel therapeutics, and actual cost experience, then trended forward using experience of national practices not in the model.

• The Target amount is then the benchmark amount with the discount rate applied

– Phased in 2 sided risk adjustment (one sided for 2 then 2 sided for 3) with 2.75% discount instead of 4% • Difference between target amount and actual expenditures (Including the patient management fee) is your performance payment which are subject to adjustment for meeting quality targets

• If practice does not achieve savings by end of year 3 they either need to adopt 2 sided risk or they are out

20 Where Can The Savings Come From: Spending on First 6 months of chemotherapy patient 45% 40% 35% 30% Chemo Inpatient 25% E&M 20% Imaging 15% XRT 10% Other A an B 5% 0%

Source: CMMI| 21 Understanding the Model

| 2 2 CONFIDENTIAL DRAFT Risk-Adjustors-Incomplete and Where the Money Is

• Cancer type • Age • Sex • Dual eligibility for Medicaid and Medicare • Selected non-cancer comorbidities • Receipt of selected cancer-directed surgeries • Receipt of bone marrow transplant • Receipt of radiation therapy • Source of episode trigger (Part B or Part D) • Institutional status • Participation in a clinical trial • History of prior chemotherapy use • Episode length • Hospital referral region

The OCM Journey | 23 CONFIDENTIAL DRAFT Importance of Comorbidities

Male age 65 with lymphoma, Part D, no Medicaid and:

33,000 $32,090.28 32,000 31,000 30,000 $29,481.21 29,000 28,000 $26,603.78 27,000 Target Price Target 26,000 25,000 24,000 $23,657.80 23,000 0 1 2 3

Comorbidities

The OCM Journey | 24 CONFIDENTIAL DRAFT

Aggregate gain: $1.8 million

The OCM Journey | 25 CONFIDENTIAL DRAFT

Aggregate Loss: $3.5 million

The OCM Journey | 26 Should We Be Held Accountable for Drug Costs? Where Can The Savings Come From: Spending on First 6 months of chemotherapy patient 45% 40% 35% 30% Chemo Inpatient 25% E&M 20% Imaging 15% XRT 10% Other A an B 5% 0%

Source: CMMI|/Abt 28 Shift from Part B to Part D Drugs

29 30 | 31 Problems With Including Drugs in Bundles • Drug Costs are Price x utilization • Even in best case, providers have limited if any ability to control drug price • The ability to control utilization is overestimated and puts oncologists at substantial risk • It is very unlikely that any bundle will be able to risk adjust or “outlier” their way out of this problem except for possibly very large practices • Bottom Line: Oncologist should never be penalized for giving the right drug, to the right patient, at the right time

| 32 Methodology

• Two Patient Populations: Stage III Colon and Stage IV NSCLC (Adeno)

• Bundle based on Q1 2016 Medicare Reimbursements and includes: Chemotherapy drugs, supportive care drugs, E&M fees, chemo admin fees

• Three scenarios were modeled for stage III colon cancer and 12 for NSCLC (coming slides)

• Models run separately for urban versus rural and follow practice sizes

– Small: 7 patients with cancer in a given period – Medium: 18 patients with a cancer in given period – Large: 42 patients with a cancer in a given period

• For each practice type, the simulation was run 1000 times to estimate the probability risk for that practice

33 Stage IV Lung Cancer

34 Lung Cancer

35

Presentation Title Here | 37 Solution To Drug Costs: Value Based Pathways

• Create deemed pathways for drugs (therapeutic and supportive), imaging, and testing • Pathway choices should be ranked based on efficacy, toxicity, and cost – Chemo+ Bev beats Chemo+ cetux in front line colon cancer • Turn Drug Utilization into a Quality Metric: Shared Savings should be reduced in some proportional manner if providers fall below a certain threshold that is not 100% (?80%) • Providers must be allowed to operate under one value- based pathway system which does not change based on patient’s insurance status Need to Come To Agreement on Value and Soon

• ICER • MSKCC Drug Abacus • ASCO Value Framework • ESMO Value Framework • NCCN Evidence Blocks Must Identify the High Risk Patients Medical Oncology Hospitalizations

Symptom High Risk for End of life related Hospitalizations hospitalizations hospitalizations

RISK SCREENERS PROMS EARLY PALLIATIVE CARE PATIENT PROFILING TRIAGE PATHWAYS ADVANCED CARE PLANNING PATIENT NAVIGATION URGENT CARE/ SAME DAY APPTS Trends in resource utilization and Medicare costs during implementation of a lay navigation program

Gabrielle Rocque, MD On behalf of the Patient Care Connect Program Investigators University of Alabama at Birmingham May 30, 2015

JAMA Oncology-2017;3(6): 817 ID High Risk Patients

• High-morbidity cancers (eg, pancreatic, ovarian, and lung), • High-risk comorbidities (eg, diabetes, heart failure, and chronic obstructive pulmonary disease) • History of ED visit or hospitalization in the prior month. Navigator Roles

• Empower patients • Care coordination • Address barriers to receiving healthcare • Pro-active management guided by frequent distress screening – Domains: Practical, Informational, Financial, Family, Emotional, Spiritual, and Physical Overall Cost by Group

Patients In PCCP 760 1793 2803 3401 4420 Navigated Patients 760 1793 2803 3401 4420 5209

$16,000 $15,091 P (time x group) < 0.0001 $14,000

$12,000

$10,000 Navigated $8,269 $8,000 Non-Navigated $5,315 $6,000

$4,000 Cost per beneficiary per quarter per beneficiary per Cost $3,593

$2,000

$0 Q3 Q4 Q1 Q2 Q3 Q4 2013 2014

Average decline of $655 per navigated patient per quarter Hospitalizations by Group

Patients In PCCP 760 1793 2803 3401 4420 Navigated Patients 760 1793 2803 3401 4420 5209

40.0% p (time x group) = 0.0399 35.8% 35.0%

30.0%

25.0%

16.1% Navigated 20.0% Non-Navigated 15.0% 10.8%

10.0% 7.5% 5.0% Beneficiaries hospitalized per per quarter hospitalized Beneficiaries

0.0% Q3 Q4 Q1 Q2 Q3 Q4 2013 2014 The Supportive Oncology Screening Tool is comprised of 10 validated (Clinical & Social) assessments that are used to determine a patient’s needs for supportive care services Supportive Oncology Assessment Referral Process

Assessment Competed By Reviewed by Referral to

For Patients >65

VES 13 MA/RN MD SOCARE Clinic Mini Cog MA/RN MD SOCARE Clinic All Patients

PHQ4 MA/RN MD Psycho Oncology

Physical Performance (Chair MA/RN MD >65 Referral to SOCARE, <65 Referral to PT Stands)

Social Support MA/RN MD-Optional

Financial Support MA/RN MD-Optional Auto-referral Social Work Health Literacy MA/RN MD-Optional

Nutrition MA/RN MD Patient Care Coordinators will schedule with Spiritual Care MA/RN MD Nutrition/Chaplains Process Overview

CARE ASSESSMENT REVIEW REFERRAL COORDINATION

• MAs will conduct the • BPA triggered • Based on either • Reporting following: based on auto capabilities for • VES-13 threshold scores referral(social research work) or • Mini Cog • Clinician • Threshold reviews Clinician action, • PQH4 adjustments triggered BPA with smart • Monitoring & • Physical assessment order set will Performance makes decision fire evaluation of • Social Support on referral • Once signed, no referral patterns • Financial Support • Will be other action • Review of • Spiritual Support repeated every needed-will supportive service • Health Literacy 3 months route to utilization appropriate • Nutrition scheduling team • Symptom Inventory MSKCC Symptom Tracking and Reporting (STAR)

Basch ASCO 2017 MSKCC Symptom Tracking and Reporting (STAR)

31 vs. 26 months; P=0.03

Basch JAMA 2017;318:197 Population (n = 221)

≥ 3 UCM ambulatory oncology encounters

Palliative Chemotherapy

Dx: leukemia, cholangiocarcinoma, esophageal, gastric, pancreatic, lung or urothelial cancer

Followed for 6-9 months or until death

| High Risk Events

Change in chemotherapy

Emergency Room visit

Hospital admission High-Risk Events Incidence Hazard n=221 Ratio* 95% CI

57 (26%) 1.50 (1.06, 2.14) 0.024 118 (53%) 1.31 (0.71, 2.41) 0.40 22 (10%) 2.52 (1.69, 3.76) <0.001 146 (66% ) 1.86 Any Event (1.26, 2.74) 0.002 CONFIDENTIAL DRAFT Investments to Target High Risk Patients

• Investment in care coordination and navigation: who, where, and what should they do?

• Staffing for after hours Urgent Care to avoid ER visits, hospitalizations and readmissions

• Staffing of additional inpatient palliative care staff: APN, social workers

• Staffing of inpatient transition of care coordinators

• Patient Reported Outcome Tools

Money cannot help solve: getting all staff to collect and act on the information provided to them

The OCM Journey | 74 Conclusions • The Transition from Volume to Value is Upon Us

• The Transition will be clumsy with competing and potentially mutually exclusive incentives along the way

• Ultimately we ask for a system which: – Rewards us for restraining unnecessary costs which are under our control – Rewards us for achieving high quality care – Does not penalize us for costs which are not under our control (drug prices) – Does not penalize us for doing the right thing for the patient (Risk Adjustment) – Does not incentivize us to do more (move away from FFS • “We better start swimmin’ Or we w’'ll sink like a stone”

75 Presentation Title Here | 76 CONFIDENTIAL DRAFT It Takes a Village

• Laurie Masuret-Baloun • Aditi Kumar • Carmen Barc • Ruchit Kumbhani • Brenda Battle • Bobby Lester IS and EPIC Administration • Brittany Beach • Rita McLoughlin • Christine Bestvina • Monica Malec Clinicians • Kelli Buckley • Christina Moore Front-line staff • Selina Chow • Heather Nelson • Toni Cipriano • Jackie Newsome-Ryan • Mark Connolly • Sandeep Parsad • William Dale • Isaac Prasad Cancer • Julie Dalla Rossa • Sam Ruokis • Chris Daugherty • Lisa Sandos Registry • Diane Davis • Ruth Shimandle • Ellen Feinstein • Cassie Simon Finance • Mayumi Fukui • Diane Smith Center for Quality • Sawanna Golden • Mary Kate Springman Managed Care • David Gaudet • Marsha Sumner • Fay Hlubocky • Meghan Valleau Diversity & Inclusion Office • Sheryl Howard • Stephen Weber • Michael Huber • James Williams • Luca Capicchioni • Lukas Rees

The OCM Journey | 77