Florida Blue Cross Blue Shield 2.9 million members in 2013

1. Florida Blue Cross, the largest commercial payer in Florida, has established an “Oncology ACO” that is one of the first specialty ACOs in the U.S. Florida Blue Cross Blue Shield 2.9 million members in 2013 17th largest commercial payer in the U.S. • Oncology accounted for 25% of total spend in 2012 with significant annual increases • Needed to find a way to control costs while maintaining quality PROBLEM Developed accountable care contracts with two of their largest providers of oncology care for six common cancer types (breast, female reproductive, male reproductive, digestive, respiratory, lymphatic, blood) SOLUTION • Moffitt Cancer Center • 330 oncologists throughout Florida • Historically provides more efficient care, but room for improvement • Physicians salaried • Baptist Health South Florida/Advanced Medical Specialties (AMS) • AMS has 46 oncologists in Miami that admit to Baptist Health South Florida • AMS is historically a high-cost practice but recognized that a change needed to happen

2. The Oncology ACO uses a “cancer year” to assess total cost of care; shared savings are determined by cost savings and quality measurement The Cancer Year Costs compared against baseline to determine shared savings Shared Savings Calculation • All fee-for-service costs for an individual patient following diagnosis • Excludes major trauma One Year Diagnosis Baseline Calculation Established baseline ACO membership in that “year” Established baseline total cost of care for the ACO membership in that year Established annual cost of care per ACO member in that year AMS example: 355 patients $27M $96,000 Physician Quality Metrics Hospital Quality Metrics • Chemotherapy regimen compliance • QOPI • “End of life” metrics • Participation in The Society of Thoracic Surgeons National Database • Participation in a Florida, or national, surgical care quality initiative • Perform at or above the Florida state average, for all reporting hospitals, for multiple CMS measures Shared savings are determined by cost savings as well as adherence to quality metrics:

3. While both institutions saw cost savings in the first year, Moffitt excelled while the Baptist/AMS partnership had to initiate an entire cultural overhaul Baptist Health South Florida/Advanced Medical Specialties (AMS) Moffitt Cancer Center • Experienced difficulty adapting to the accountable care environment • An overall culture change needed to be had in both institutions (historically fee-for-service and focused on chemotherapy margins to drive revenue) • Different IT systems between AMS/ Baptist Health made care coordination difficult • Small improvement in cost trend in the first performance year of the program • Structural necessities were in place to achieve success • All physicians are salaried, and there is an ingrained culture of providing efficient, quality care, making improved care management an easier task • Projected to be able to recognize 7-figure savings in the first year of the program (2013) • Florida Blue is still trying to identify specifically where cost savings were derived, although they do know that some cost savings came from reduced chemotherapy use • Florida Blue recognizes that the easiest way to achieve savings is by reducing the quantity of services rendered, but they are hoping to drive an overall culture change where physicians understand their risk and financial responsibility while working to achieve the highest quality care