Site of Care Matters:
This presentation is the property of its rightful owner.
Sponsored Links
1 / 40

Site of Care Matters: The Value of Community Oncology PowerPoint PPT Presentation


  • 142 Views
  • Uploaded on
  • Presentation posted in: General

Site of Care Matters: The Value of Community Oncology. The Payer Value Proposition. September 2012. Prepared for ION Solutions. Outline. Current State of Oncology Management. Community vs Hospital-based Oncology Care. Changing Oncology Landscape. The Value of Community Oncology.

Download Presentation

Site of Care Matters: The Value of Community Oncology

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Site of care matters the value of community oncology

Site of Care Matters: The Value of Community Oncology

The Payer Value Proposition

September 2012

Prepared for ION Solutions


Outline

Outline

Current State of Oncology Management

Community vs Hospital-based Oncology Care

Changing Oncology Landscape


The value of community oncology

The Value of Community Oncology

  • Patients managed in an office-based setting are less costly than those managed in hospital outpatient settings

Care provided in a community office-based setting is more accessible and less costly for patients

  • Patients in community settings utilize more generics and less brand therapies, which results in savings for payers

Community practices are more willing to participate in pay-for-quality pathway programs, which will translate into improved outcomes and savings for payers


Current state of oncology management

Current State of Oncology Management


Site of care matters the value of community oncology

Consolidation in the cancer care landscape continues as larger hospital groups acquire, purchase, or merge with private, community-based practices

Changing Business Structure of 1,254 Oncology Clinics/Practices From 2008–20121

241 Clinics Closed

442 Practices Struggling Financially

47 Practices Sending Patients Elsewhere

392 Hospital Agreement/Purchase

132 Merged/Acquired by Another Entity

  • Practice Impact Report. Community Oncology Alliance. April 4, 2012. http://www.communityoncology.org/pdfs/community-oncology-practice-impact-report.pdf Accessed August 23, 2012


Site of care matters the value of community oncology

In 2011, nearly 1 in 4 practices (24%) indicated that they are currently changing their business structure or may only remain viable for another year or so

How long to you expect this business structure will remain unchanged and viable?

24%

  • Barr TR, Towle EL. National Oncology Practice Benchmark, 2011 Report on 2010 Data. J Onc Pract. 2011;7(6S):67S-82S.


Payers understanding of the issue

Payers’ Understanding of the Issue

  • Payers understand that oncology is unique and must be approached differently than other specialties

  • Payers often consider 2 opposing goals when managing oncology1

    • Find ways to more aggressively control oncology spending

    • Craft management policies that are politically and clinically defensible

  • Payers focus their management attention on the most prevalent and high-cost cancer types to generate the largest return for their efforts in developing and implementing management programs

    • These cancer types are:

Breast

Lung

Colon

  • McConnell K, Wu J, Dautel N. Payers Must Create Defensible Oncology Management Strategies. Oncology Business Review. 2010


Payers prioritize costs before other relevant oncology issues like site of care

Payers prioritize costs before other relevant oncology issues, like site of care

  • Although the provider landscape in oncology is rapidly changing, payers prioritize other aspects of oncology care before the movement of community-based care to hospital-affiliated practices

  • Priorities remain cost drivers such as the cost of hospitalizations or the cost of high-priced products

Payer Priorities in Oncology1

High-priced new products

Cost of hospitalizations

Ability to compare and analyze pharmacy and medical benefit

Need to increase use of generics

Appropriate use of biomarkers

Pathway implementation

Appropriate use of hospice

Compliance and persistency with oncology drugs

Cost of emergency room visits

Movement of community-based care to hospital-affiliated practices

Role of 340B

  • Xcenda. Managed Care Network. PayerPulse June 2012.


Site of care matters the value of community oncology

There also appears to be a disconnect between payer and provider preferences for acquiring infused therapies; payers prefer SPP, while providers demonstrate a preference for buy-and-bill

Providers’ Primary Infused Therapy Acquisition Channel1

  • >70% of infused therapies for oncology are distributed via buy-and-bill1

  • Average sales price (ASP) used as the primary method of reimbursement by payers

  • Snyder M, Goldberg L, Ryan T. Payer Management of Oncology Gets Serious. Pharmacy Times. http://www.pharmacytimes.com/publications/specialty-pt/2011/May2011/Payer-Management-of-Oncology-Gets-Serious. Accessed August 17, 2012.


The challenge of establishing the site of oncology care payer value proposition

The Challenge of Establishing the Site of Oncology Care Payer Value Proposition

  • There is somewhat of a disconnect between payers and oncology providers

    • Payers have other priorities in oncology that supersede site of care, despite the recent market changes

      • Payers lack awareness of the value that community oncology practices bring to the market

    • Preferences for product acquisition vary and create an additional point of discussion and negotiation between the 2 groups

      • Payers are seeking additional payment models that make oncology practices’ income independent of drug selection and reward physicians for improving outcomes and reducing costs

  • As heard in a recent payer focus group, smaller regional payers may have different views, needs, and opinions than larger national payers1

    • National payers may have more lucrative contracts with hospitals, particularly larger hospital systems, than with smaller community practices, and therefore, may see comparable costs in patients treated in the hospital outpatient department (HOPD) setting

      • The opposite being true for smaller payers

      • Mid-size plans are more undecided and potentially able to be persuaded either way

  • Payers are also looking for a demonstration of quality as part of the value equation1

    • ie: Value = Quality / Cost

  • Xcenda, data on file. Oncology Site of Care Virtual Payer Council. September 2012.


Community vs hospital based oncology care

Community vs Hospital-based Oncology Care


Site of care matters the value of community oncology

While HOPDs often profess to care for sicker patients to justify their higher costs, recent claims analyses show similarities in the demographics of office-managed vs HOPD-managed breast, lung, and colorectal cancer patients1

  • Slightly more females than males are treated in the HOPD compared to community practices

  • The mean age of patients in the community practice setting is slightly higher than in the HOPD setting (58.7 years vs 56.9 years, respectively)

  • Patient illness severity is roughly the same in the community practice setting as the HOPD setting across these 3 tumor types

  • Xcenda, data on file. Site of Care Claims Analysis Report. September 2012.


The value of community oncology1

The Value of Community Oncology

  • Three separate analyses of managed care claims in commercial and Medicare populations demonstrate that patients managed in a community office setting cost less than patients managed in a hospital-based outpatient setting1-3

    • The difference in cost varies for individual tumor types; however, the data suggest that this applies to breast, lung, and colorectal cancer3

  • Evidence suggests that patients managed in a community office setting have lower hospitalization rates than patients managed in a hospital-based outpatient setting

  • The majority of common breast, colorectal, and lung cancer chemotherapy-specific costs are lower for patients managed in a community setting

Patients managed in an office-based setting are less costly than those managed in hospital outpatient settings

  • Avalere Health Analysis Report of National Association of Managed Care Physicians member data. Total cost of cancer care by site of service: physician office vs outpatient hospital. March 2012.

  • Fitch K, Pyenson B. Site of service cost differences for Medicare patients receiving chemotherapy. Milliman Client Report. 2011.

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

Analysis of 4 large commercial health plans reveals that patients who are managed in an office setting are 24% less costly than hospital-managed patients for common cancer types1

  • Avalere Health Analysis Report of National Association of Managed Care Physicians member data. Total cost of cancer care by site of service: physician office vs outpatient hospital. March 2012.


Site of care matters the value of community oncology

There was a 114% difference in the average cost of episodes for office-managed patients ($26,800) vs HOPD-managed patients ($57,400) over 9 months1

  • Avalere Health Analysis Report of National Association of Managed Care Physicians member data. Total cost of cancer care by site of service: physician office vs outpatient hospital. March 2012.


Site of care matters the value of community oncology

In a Medicare population, office-managed patients cost $6,500 less per year than hospital-managed patients

  • Fitch K, Pyenson B. Site of service cost differences for Medicare patients receiving chemotherapy. Milliman Client Report. 2011.


Site of care matters the value of community oncology

Hospital-managed patients with breast, colorectal, and lung cancer were more costly than community-managed patients1

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

Breast cancer patients managed in a hospital-based setting are more costly in all treatment categories1

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

Colorectal cancer patients managed in a hospital-based setting are more costly in all treatment categories except bone metastasis agents1

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

Lung cancer patients managed in a hospital-based setting are more costly in most treatment categories1

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


In the same analysis office managed patients also had fewer hospitalizations during chemotherapy

In the same analysis, office-managed patients also had fewer hospitalizations during chemotherapy

  • An analysis of 3 years of commercial health plan data reveals that oncology patients treated in an HOPD have higher hospitalization rates

  • Office-managed

  • 11 out of every 100 patients had at least 1 hospitalization during the chemotherapy episode

  • HOPD-managed

  • 14 out of every 100 patients had at least 1 hospitalization during the chemotherapy episode

  • Avalere Health Analysis Report of National Association of Managed Care Physicians member data. Total cost of cancer care by site of service: physician office vs outpatient hospital. March 2012.


Site of care matters the value of community oncology

The majority of common breast, colorectal, and lung cancer chemotherapy-specific costs are lower for patients managed in a community setting1

Key: CPL – carboplatin, CTX – cyclophosphamide, DOXO – doxorubicin, DTX – docetaxel, ZA – zoledronic acid

Key: CPL – 5-FU – fluorouracil, BEV- bevacizumab, LV – leucovorin, OX - oxaliplatin

Key: BEV- bevacizumab, DTX – docetaxel, ETO – etoposide, GC – gemcitabine, PL – platinum, PTX – paclitaxel, TPT – topotecan, VNR - vinorelbine

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

HOPD costs are 40% to 54% higher than community practices for patients receiving non-targeted chemotherapy in breast, lung and colorectal cancers. This is primarily driven by physician costs being 89% to 1242% higher in HOPD vs community1

$15,902

$13,632

$13,149

$10,345

$9,580

$9,403

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

HOPD costs are 30% to 97% higher than community practices for patients receiving targeted chemotherapy in breast and colorectal cancers; however, lung cancer costs are comparable1

$32,010

$20,236

$15,050

$14,891

$15,545

$16,214

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


The value of community oncology2

The Value of Community Oncology

Care provided in community office-based settings is more accessible and less costly for patients

  • Patient out-of-pocket amounts are higher for patients managed in an HOPD setting

  • Most common chemotherapy regimens for breast, colorectal, and lung cancers are associated with lower patient out-of-pocket payments in a community office setting

  • When patients receive care in an HOPD setting, they are more likely to wait longer for their first chemotherapy treatment

  • Patients in rural areas are more likely to visit community office practices, indicating that community care is more accessible to these populations


Site of care matters the value of community oncology

In a Medicare population, patient out-of-pocket amounts are 10% higher for patients receiving chemotherapy in hospital outpatient settings1

84% of oncologists say that patients’ out-of-pocket spending influences treatment recommendations2

  • Fitch K, Pyenson B. Site of service cost differences for Medicare patients receiving chemotherapy. Milliman Client Report. 2011.

  • Neumann P, Palmer J, Nadler E, et al. Cancer therapy costs influence treatment: a national survey of oncologists. Health Affairs. 2010;29(1):196-202.


Site of care matters the value of community oncology

With respect to common breast, colorectal, and lung chemotherapy regimens, most patient out-of-pocket costs are higher for hospital outpatient-managed patients1

Key: CPL – carboplatin, CTX – cyclophosphamide, DOXO – doxorubicin, DTX – docetaxel, ZA – zoledronic acid

Key: CPL – 5-FU – fluorouracil, BEV- bevacizumab, LV – leucovorin, OX - oxaliplatin

Key: BEV- bevacizumab, DTX – docetaxel, ETO – etoposide, GC – gemcitabine, PL – platinum, PTX – paclitaxel, TPT – topotecan, VNR - vinorelbine

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

Access to community clinics is vital for patients in rural areas and Medicare beneficiaries without supplemental insurance1

  • Shea AM, Curtis LH, Hammill BG, et al. Association between the Medicare Modernization Act of 2003 and patient wait times and travel distance for chemotherapy. JAMA. 2008;300(2):189-196.


Changing oncology market landscape

Changing Oncology Market Landscape


The value of community oncology3

The Value of Community Oncology

  • Patients in community settings utilize more generics and less brand therapies, which result in savings for payers

  • Breast, colorectal, and lung patients managed in a community setting are prescribed generic chemotherapy more frequently

  • The maturing oncology portfolio will bring savings through competition and higher generic utilization in a community setting

  • Breast, colorectal, and lung patients managed in a hospital setting are prescribed brand treatments more frequently

  • An active pipeline creates more opportunity for payers to adopt aggressive management policies for hospital-based providers with high brand utilization


Site of care matters the value of community oncology

Breast, colorectal, and lung patients managed in a community setting are prescribed generic chemotherapy more frequently1

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

The maturing oncology portfolio will bring savings through competition and higher generic utilization in a community setting

2017

Neulasta

Sandostatin

Velcade

Tysabri

Iressa

Velcade

Xolair

2014

Remicade

Leukine

Rapamune

Evista

Xeloda

2016

Enbrel

Erbitux

Zevalin

Elitek

Humira

Prialt

2021

Sutent

Soliris

2023

Thalomid

2013

Neupogen

Zometa

Xeloda

Taxotere

Temodar

Dacogen

Epogen

Procrit

Remicade

2020

Nexavar

Tykerb

Revlimid

Vectibix

Sprycel

2012

Eloxatin

Enbrel

Vidaza

2018

Tarceva

Avastin

Herceptin

Clolar

2011

Etopophos

Xeloda

Aromasin

Femara

Anzemet

Istodax

Plavix

Avonex

Neumega

2019

Revlimid

Zytiga

Exjade

Boniva

Orencia

2015

Epogen

Aranesp

Rituxan

Epogen

Procrit

Gleevec

Aloxi

Neulasta

Peg-Intron

Emend oral

Alimta

2008

Femara

Camptosar

Fosamax

185% increase in available generics/biosimilars

2007

Kytril

Gemzar

By 2020, there will be a robust portfolio of generic and biosimilar treatments

2006

Zofran

2005

Duragesic Transdermal

Sandostatin

Patent Expiration

Generic Introduced


Site of care matters the value of community oncology

Breast, colorectal, and lung patients managed in a hospital setting are prescribed brand treatments more frequently1

  • Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Site of care matters the value of community oncology

An active pipeline creates more opportunity for payers to adopt aggressive management policies for hospital-based providers with high brand utilization

  • The presence of numerous treatment options gives payers the opportunity to adopt more aggressive management policies by leveraging competitive market dynamics


The value of community oncology4

The Value of Community Oncology

Community practices are more willing to participate in pay-for-quality pathway programs, which will translate into improved outcomes and savings for payers

  • Evidence demonstrates community oncology practices are more likely to participate in pathways or pay-for-quality programs

  • Pathway programs result in reduced costs of cancer care by reducing the rate of both drug and nondrug expenses

  • High community practice participation rates in pathways programs creates an opportunity for payers to improve care and reduce costs


Site of care matters the value of community oncology

An opportunity exists for payers to leverage community oncology practices’ willingness to participate in pay-for-quality pathway programs

  • Evidence demonstrates community oncology practices are more likely to participate in pathways or pay-for-quality programs1

    • In a study where 362 oncology practices were eligible for participation, the highest participation rate was observed in community oncology practices1

    • In a related study, the pathway program resulted in reduced costs of cancer care by reducing the rate of both drug and nondrug expenses2

    • Total savings, factoring out the increased fee schedule for participating practices, was estimated at $8,585,1482

  • Furthermore, pilot pathways programs suggest that the saliency of pay-for-quality incentives in academic and hospital settings should be further studied1

  • Fortner BV, Wong W, Olson T, et al. Year one evaluation of participation and compliance in regional pay for quality (P4Q) oncology program. Poster presented at: International Society for Pharmacoeconomics and Outcomes Research; Atlanta, GA: May 15–19, 2010.

  • Scott JA, Wong W, Olson T, et al. Year one evaluation of regional pay for quality (P4Q) oncology program. J Clin Oncology. 2010;28(Supl 15):6013.


Summary

Summary


The value of community oncology5

The Value of Community Oncology

  • Three separate analyses of managed care claims in commercial and Medicare populations demonstrate that patients managed in a community office setting cost less than patients managed in a hospital-based outpatient setting

  • Patients managed in a community office setting have lower hospitalization rates than patients managed in a hospital-based outpatient setting

  • The majority of common breast, colorectal, and lung cancer chemotherapy-specific costs are lower for patients managed in a community setting

Patients managed in an office-based setting are less costly than those managed in hospital outpatient settings

Care provided in a community office-based setting is more accessible and less costly for patients

  • Patient out-of-pocket amounts are higher for patients managed in an HOPD setting

  • Most common chemotherapy regimens for breast, colorectal, and lung cancer are associated with lower patient out-of-pocket payments in a community office setting

  • When patients receive care in an HOPD setting, they are more likely to wait longer for their first chemotherapy treatment

  • Patients in rural areas and Medicare patients without supplemental insurance are more likely to visit community office practices, indicating that community care is more accessible to these populations

  • Breast, colorectal, and lung patients managed in a community setting are prescribed generic chemotherapy more frequently

  • The maturing oncology portfolio will bring savings through competition and higher generic utilization in a community setting

  • Breast, colorectal, and lung patients managed in a hospital setting are prescribed brand treatments more frequently

  • An active pipeline creates more opportunity for payers to adopt aggressive management policies for hospital-based providers with high brand utilization

Patients in community settings utilize more generics and less brand therapies, which results in savings for payers

  • Evidence demonstrates community oncology practices are more likely to participate in pathways or pay-for-quality programs

  • Pathway programs result in reduced costs of cancer care by reducing the rate of both drug and nondrug expenses

  • High community practice participation rates in pathways programs creates an opportunity for payers to improve care and reduce costs

Community practices are more willing to participate in pay-for-quality pathway programs, which will translate into improve outcomes and savings for payers


Recommendations

Recommendations

  • Know your audience:

    • The value messages (as described on the previous slide) are likely to resonate best with small to mid-size payers

      • Educate on cost and quality outcomes in the community setting compared to the HOPD setting

      • Smaller payers are likely more in touch with the local providers already, and therefore likely need less convincing; mid-size payers are likely to need the most education and persuading

      • Understand the hospital contracts and other drivers for large plans before approaching with these messages and tailor them accordingly

  • Generate and publish outcomes data to complete the value equation:

    • While it has been demonstrated that community practices are more likely to follow and participate in pay-for-quality programs, the outcomes of those initiatives have not been widely analyzed and published – more data generation and publication on outcomes are needed


Site of care matters the value of community oncology

  • Thank you!


  • Login