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Innovative Cancer Care Initiative #2: The Oncology ACO Marc Samuels, J.D., M.P.H. Jonathan Gavras , M.D., FCCP Leon PowerPoint Presentation
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Innovative Cancer Care Initiative #2: The Oncology ACO Marc Samuels, J.D., M.P.H. Jonathan Gavras , M.D., FCCP Leonard A. Kalman , M.D. Introduction. An Update on the Baptist Health South Florida, Florida Blue, Advanced Medical Specialties Oncology-Specific ACO

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Innovative Cancer Care Initiative #2:

The Oncology ACO

Marc Samuels, J.D., M.P.H. Jonathan Gavras, M.D., FCCP

Leonard A. Kalman, M.D.

introduction
Introduction
  • An Update on the Baptist Health South Florida, Florida Blue, Advanced Medical Specialties Oncology-Specific ACO
  • Our speakers today are Jonathan Gavras M.D., Senior Vice President Delivery Systems and CMO, Florida Blue and Leonard KalmanM.D., Chairman, Advanced Medical Specialties and Deputy Medical Director, Baptist Health Cancer Institute
  • My name is Marc Samuels, CEO of ADVI, an advisory services consultancy in Washington, DC frequently at the center of the business of oncology, politics, and access. Forty Seven percent of our portfolio is on oncology across the life sciences, digital health and services.
introduction1
Introduction
  • The panel today is of great interest to me as much of what we do is focus on the shift from fee-for-service to pay-for-value, in particular, innovative payment reforms and ACOs in the oncology space
  • From our perspective – both inside the beltway and from on the ground implementation, this panel represents one of the leading edge examples of private sector innovation in care process and payment re-design in oncology
  • Please welcome Drs. Gavras and Kalman
2013 cancer center business summit

2013 CANCER CENTER BUSINESS SUMMIT

An Update on the

Baptist Health South Florida,

Florida Blue,

Advanced Medical Specialties Oncology-Specific ACO

why call our project an aco
Why Call Our Project an ACO?
  • We are pursuing the “triple aim”
    • improving the patient experience of care (both quality and satisfaction)
    • improving the health (“care”) of populations
    • reducing the per capita cost of healthcare (actual cost reduction or a “bending of the cost curve”)
  • We are focusing on a specific “attributed” population
  • The providers are being paid “fee for service” with a concomitant “shared savings” agreement
why an oncology specific aco
Why An Oncology-Specific ACO?
  • Because of the spend
    • U.S. healthcare spend $2.7 trillion
    • cancer spend about 5% of that or $125 billion
    • cancer spend about 10% of the total Medicare spend
    • adage that 20% of the patients spend 80% of the dollars (cancer patients within that 20%)
why was the miami market ready
Why Was The Miami Market Ready?
  • Advanced Medical Specialties
    • key “trusting” personal relationships (breaking down “historic barriers”)
    • “sole” provider of medical oncology services throughout Baptist Health
    • buffeted by prevailing community oncology “market forces”
    • appetite to innovate and learn how to assume/share “risk”
  • Baptist Health
    • market/financial dominance, but a desire to “lead” change
    • looking ahead to controlling cancer care costs in their large CIN
  • Florida Blue
    • reduce cancer care costs or at least “bend the cost curve” (pre-project “cancer care” inflation rate of 10%)
    • encourage providers to “move down the road”
    • ultimately achieve an improved reimbursement position with Baptist Health
why was the miami market ready cont d
Why Was The Miami Market Ready? (cont'd)
  • All three parties agreed on some key assumptions and goals
    • the medical oncologist is the “primary care physician” for the cancer patient (and their practice their natural “oncology medical home”)
      • “adjuvant episode”
      • “metastases to end of life”
    • every (“most”) ACO/CIN (hospital system driven or physician initiated) is looking for an “oncology solution”
    • every managed care organization would encourage oncology providers (physicians and hospitals) to participate in such initiatives so as to speed the “move down the road” to value-based payment/”risk” assumption/sharing
    • medical oncologists view such initiatives as means to maintain “control” of their patients/“protect” their income
an overview of the oncology specific aco contract
An Overview Of The Oncology-Specific ACO Contract
  • Fee for service would be maintained
  • We agreed to work together to improve the patient experience, improve the quality of care, and reduce spending/”bend the cost curve”
  • We agreed to share the savings that would (might) be derived from our mutual efforts
how did we do the attribution of cancer patients in our baseline population
How Did We Do The Attribution Of Cancer Patients In Our Baseline Population?
  • We targeted patients with the most common cancers (breast, digestive system, leukemia and lymphoma, female reproductive, male reproductive, respiratory)
  • Any member with a claim (all claims for all services),dated 8/1/10 to 7/31/11 (the “baseline period”), in Miami-Dade, for one of the six targeted cancers, with 3 or more E&M services with AMS, was attributed
    • “total cost of care” (all “adjudicated” claims) (a few “excepted” DRG’s)
    • no “outliers” or “dollar caps”
the oncology specific aco contract
The Oncology-Specific ACO Contract
  • Three “annual reconciliation periods” were defined
  • Reconciliation to be done annually ; reporting quarterly
  • Same attribution methodology in each subsequent “annual reconciliation period”
the oncology specific aco contract cont d
The Oncology-Specific ACO Contract (cont’d)
  • No payout of shared savings if certain “quality metrics” were not met
    • AMS (chemotherapy regimen compliance; QOPI certification; track “end of life” metrics)
    • Baptist Health (national thoracic; surgical care quality; CMS measures)
the baseline population and spend
The Baseline Population and Spend
  • 226 patients “became” members (commercial patients only)(fully insured and self insured)
  • $23,054,596“total cost of care”
  • “Average annual cost of care per ACO member” in the baseline year was $102,295
the oncology specific aco contract cont d1
The Oncology-Specific ACO Contract (cont’d)
  • We define (A) as the “average annual cost of care per ACO member” for the baseline year (taking into account medical CPI)
  • We do a calculation of a “provider attributed total cost of care per member per year” (B) (using a weighted average methodology) in any given “annual reconciliation period”
  • We divide (B) by (A) in any one “annual reconciliation period” to define the percent savings
    • the parties share savings only if (B) divided by (A) is less than or equal to .98
shared savings calculation example
Shared Savings Calculation Example
  • SAVINGS CALCULATION:
    • Baseline Cost of Care PMPY, Adjusted by Medical CPI (A) $ 105,000
    • Actual Cost of Care PMPY (B) $ (100,000)(.95)
    • Savings PMPY $ 5,000
    • # of Members Year 1 200
    • Savings to be Shared by the Three Parties $1,000,000
  • SHARED SAVINGS ALLOCATION:
    • AMS 25% $ 250,000
    • Baptist Health 15% $ 150,000
    • Florida Blue 60% $ 600,000

100% $1,000,000

the actual work of the oncology specific aco
The Actual “Work” Of The Oncology-Specific ACO
  • We looked at the baseline year’s spend breakdown and prioritized
  • We made certain assumptions (general)
      • focusing on patient education and the patient experience (understanding one’s illness; appropriate setting of goals; a focus on symptom control and other needs; allying with key health care surrogates) are key elements for success
      • the chemotherapy spend is always important
      • 75-80% of cancer patients who go to the ER get admitted to the hospital
      • most hospital admissions for cancer patients occur in the last 90 days of life, and are for symptoms of progressive cancer, not cancer treatment
      • hospice or “hospice-like” services are underutilized
      • “aggressive” advance care planning and “innovative” application of “palliative care” would lead to “better” patient choices at the end of life
the actual work of the oncology specific aco cont d
The Actual “Work” Of The Oncology-Specific ACO (cont’d)
  • More assumptions (market specific)
      • AMS had already embedded USON Level 1 pathways in their EMR
      • Baptist Health’s high allowables made “hospital admissions” and “length of stay” obvious “low hanging fruit”
      • the same true was potentially true for the “institutional surgery/anesthesia” spend
      • Baptist Health and Florida Blue were willing to contribute financially to this effort
the care process work of the oncology specific aco
The “Care Process” “Work” Of The Oncology-Specific ACO
  • Chemotherapy and supportive care drugs
    • strict adherence to pathways
      • requires a well-defined, tightly managed approval process
      • both for chemotherapy and supportive care drugs
      • ferret out “leakage” to the higher cost hospital setting
    • began work on “palliative care” efforts that will lead to fewer lines of treatment
the care process work of the oncology specific aco cont d
The “Care Process” “Work” Of The Oncology-Specific ACO (cont’d)
  • “Admission avoidance” measures
    • chemotherapy education
    • daytime practice “mid-level” FTE (in office; in ER [identifying the patients])
    • “not yet” for nights and weekends
    • avoid re-admissions
      • “transition of care” work
        • an in-hospital practice “mid-level” FTE, “coordinated” with assets of the other parties
    • began work on “palliative care” efforts that will lead to fewer visits to the ER and fewer admissions
the care process work of the oncology specific aco cont d1
The "Care Process" “Work” of the Oncology-Specific ACO (cont’d)
  • Shorten “length of stay”
    • an in-hospital practice “mid-level” FTE “coordinated” with assets of the other parties
  • Surgery and anesthesia
    • broke down the spend in detail
  • High tech imaging and radiation therapy
    • third parties
    • need guidelines
the oncology specific aco data
The Oncology-Specific ACO Data

EMERGENCY ROOM VISITS

the oncology specific aco data cont d
The Oncology-Specific ACO Data (cont’d)

AVERAGE LENGTH OF STAY (ALOS)

lessons learned to date
Lessons Learned To Date
  • Pick committed partners
  • Designate a “go to person” from each party
    • deliverables and timelines
  • Streamline the early data exchange
    • terminology
    • in sequence
  • Should “bending the cost curve” be rewarded (albeit less) as well (as opposed to only rewarding an actual reduction of the spend)?
  • “Small numbers” of patients leads to “large variations” in data from reporting period to reporting period
lessons learned to date cont d
Lessons Learned To Date (cont’d)
  • All constituents should understand that “signing” the contract is just the beginning of the “process,” and not an end unto itself
  • Once one oncology-specific ACO is begun, it behooves the practice to create similar projects with as many payers as possible
    • best care defined
    • the more patients, the better the data
  • The medical oncology practice “de facto” becomes the “oncology medical home” for the ACO’s patients
lessons learned to date cont d1
Lessons Learned To Date (cont’d)
  • The managed care plan can proactively support the “process”
    • favorable contracting with the practice
      • including “special” codes for treatment management in lieu of drug “margin”
      • including co-insurance issues (hospital vs office)
    • reduce onerous pre-authorizations and other “third party” initiatives
    • support chemotherapy education, advance care planning, palliative care, and transition of care
      • forgive co-pays
      • waive “two in a day” exclusions
      • patient “rewards”
      • contribute to funding of necessary FTE’s
next steps for the oncology specific aco
Next Steps For The Oncology-Specific ACO
  • What IT platform and what software and analytic tools will help us do this work faster/better?
    • better analytics
    • in real time
    • “cause and effect”
  • Take a “deep dive” in each of the “spend” areas and look for other opportunities to appropriately reduce costs
  • All three parties need to discuss the “dive;” are there some areas where we have already maximized savings (do we need to consider “reverse” “site of care shift” [will it be acceptable])
  • Consider mid-level FTE for nights and weekends
next steps for the oncology specific aco cont d
Next Steps For The Oncology-Specific ACO (cont’d)
  • Hire a palliative care physician (with the support of all three parties)
  • Develop (or buy) diagnostic radiology and radiation therapy guidelines and adapt (get buy-in from all three parties)
  • “Officially” become an “oncology medical home” so that the practice becomes “officially” responsible for total cost of care (and gets paid for it)
  • Launch additional such ACO’s
  • Work closely with our CIN to ultimately direct its cancer patients to our “oncology medical home”
next steps for the oncology specific aco cont d1
Next Steps For The Oncology-Specific ACO (cont’d)
  • Tie these ACO efforts into the Baptist Health Cancer Institute
  • Modify contracting
    • change timing of attribution
      • only after practice assumes care
    • is a -2% target too aggressive
    • would a “cancer CPI” be more appropriate than a medical CPI
    • take into account certain outliers
      • transplants (dollar caps)
      • long, complicated admissions (dollar caps)
      • don’t let a few large spenders in a small category skew the numbers (lump the categories)
    • should surgery and anesthesia be counted