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Oncology Outcomes

Oncology Outcomes. Introduction to Cancer DM Gus Manocchia, MD – BCBS of RI Rick Lee – Quality Oncology. May 13, 2003. Who Gets Cancer?. 77% of cancer cases are diagnosed in people > 55 1,334,100 new cases are diagnosed each year Direct Cost of cancer in 2002 was $60.9 Billion.

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Oncology Outcomes

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  1. Oncology Outcomes Introduction to Cancer DM Gus Manocchia, MD – BCBS of RI Rick Lee – Quality Oncology May 13, 2003

  2. Who Gets Cancer? • 77% of cancer cases are diagnosed in people > 55 • 1,334,100 new cases are diagnosed each year • Direct Cost of cancer in 2002 was $60.9 Billion Source: American Cancer Society 2003 Facts & Figures

  3. Why Manage Cancer?

  4. “When you have a hammer, everything looks like a nail”

  5. Prostate Cancer: 1st Referral = Intervention Duval Baker Clay Volusia Lake Seminole Citrus Orange Hernando Pasco Brevard Hillsborough Polk Pinellas Okeechobee St. Lucie Highlands Martin Sarasota Glades Charlotte Palm Beach Lee Broward Dade Monroe 240% Variation (FN) Tampa Prostatectomy: 1.0/1000 men St. Petersburg: 3.4/1000 men Source: Wennberg, J. Dartmouth Atlat of Health Care (1998)

  6. Prostatectomy: High Volume Caseload Better High volume correlates positively with: 8.2% • Lower risk of readmissions • Serious complications • Lower risk of mortality within 30 days N = 101,604 Low Volume ALOS High Volume ALOS Source: Yao, S-L, Lu-Yao G. “Population-Based Study of Relationships Between Hospital Volume of Prostatectomies, Patient Outcomes, and Length of Hospital Stay.” Journal of National Cancer Institute, 1999, 91:1950-1956

  7. Patient Issues Regarding End of Life 80% want to avoid hospitalization and intensive care at end of life Chance of being in intensive care is 45% in last 6 mos. 70% wish to die at home; 25% of Americans die at home 28% of hospice patients die within first week of admission Dying in America, Last Acts’ 11 Committees, Nov 2002

  8. Theoretical Actual 88.4% 43% Poll of 800 Oncologists in the European Society of Medical Oncologists, surveyed in July 2002 by N Cherny, MD Coordination of End of Life Care

  9. Today’s Unmanaged Cancer Physicians Undersupplied Too many patients/MD: 8 minutes/patient Reactive Resent oversight Treatment variation near end of life Rely on hospitals for emergencies Averse to alternative medicine Don’t welcome discussing death with patients

  10. Communication About Death With Patient 40% Physician overly optimistic in projecting likelihood and date of death 37% Physician levels honestly with patient 23% Physician refuses patient request to prognosticate N. Kristokas, MD et al, Annals of Internal Medicine, June, 2001

  11. “Are My Side Effects Life Threatening? • Fatigue • Hair Loss • Stomatitis • Mucositis • Diarrhea • Tissue Damage • Acne • Dry Skin Anemia Nausea and Vomiting Infection Irritable Bowel Kidney and Bladder damage Constipation Fluid retention Peripheral Neuropathy

  12. 62% 43% 41% 38% 34% Lung Genito- Gastro- Breast Lymphoma urinary intestinal Cancer Patients Receive Inadequate Analgesia N =522

  13. Summer 2000:Dot Com BombingAl vs. GeorgeBCBSRI Decides to Act

  14. BCBS of Rhode Island Project • BCBS Membership vs. Other Health Plans • Higher prevalence • More inpatient use • More short stays that could be averted • Much greater ER use • Program Expectations • Move chemo out of hospital • Increase hospice use and LOS • Avert unnecessary ER visits

  15. Commercial Cancer Prevalence 1999 Blue CHiP data: 625 Malignant Cancer Patients out of 49,082 Commercial HMO members.

  16. Hospital Use - Commercial 1999 Blue CHiP data: 303 Admissions lasting 1,882 days from 49,082 Commercial HMO members.

  17. Admission Volume and Costs by Length of Stay

  18. ER Visits - Commercial 1999 Blue CHiP data: 178 ER visits from 49,082 Commercial HMO members.

  19. PROVIDER RESPONSE IN R.I. • Reasons many physician groups unwilling to participate: • “We have our own staff providing this care” • “This is just another layer of bureaucracy between me and my patient” • “This is too much paperwork for which I receive no compensation” • “How can a telephonic nurse in Virginia give my patient the same level of assistance as my in-house nursing staff or me?”

  20. LESSONS LEARNED • Convene Provider Forums… include: • Surgeons, • PCPs, • Medical Oncologists, • Radiation Oncologists • Obtain “buy-in” from high volume groups • Work proactively with the Payer Contracting Dept. • Reimburse for referrals to program • Widely publicize any early successes

  21. How QO Performs Cancer Disease Management

  22. What is QO? • Largest cancer care management company in U.S. • 17 clients; >5 million lives • Founded in ’93; 3 offices (FL,CA,VA) • Offers a Provider and Patient solution • Licensed Oncology Nurse Care Managers • 24/7 access and support • Focus: Manage hospital usage more effectively • URAC accredited • 5000 patients under management today

  23. QO’s Management Tools Data Analysis Telephonic Nurse Care Management Treatment Authorization Guidelines Integrated Care Management System

  24. QO role begins at identification of cancer patients 28% of cases are stratified for active case mgmt Seasoned Oncology RNs in call centers Proactive Counseling and Side Effect Management Treatment Plan = Roadmap for proactive CM 24 x 7 access Peer-to-Peer Medical Director Consultations Outsourced Telephonic Care Management

  25. Communication About Values With Patient < 1 Month Diagnosis Unmgd Attack Cancer Aggressively Pain Hospice Referral Management Diagnosis Attack Cancer Aggressively Anticancer Treatment QO Supportive Care Palliative Care Psychosocial Counseling Pain Management Cancer Rehabilitation Advanced Care Planning Hospice Referral Ongoing Symptom Management Nutrition Services Fatigue Management

  26. QO’s Historical Experience with Treatment Plan Reviews Cancer Cases 1% of Commercial Membership 60% Ruled out by stratification criteria 25.2% Plans approved Data discrepancies 11% Peer to peer Discussions 3.6% 0.2% Recommend not to authorize Minimal MD Hassle

  27. Savings by Category Reduction in Coordination Readmits of End of Life Averted ER Visits Management of Complication Rates Chemo/Rad Cost Savings Areas of Impact

  28. 3.50 11% Two- Year Reduction 3.00 14% Two- Year Reduction 2.50 2.00 Acute Hospital Days per Cancer Case 3.51 3.04 3.00 1.50 2.79 2.68 2.48 1.00 0.50 0.00 Commercial: Commercial: PY1 Commercial: PY2 Medicare Risk: Medicare Risk: Medicare Risk: Baseline Baseline PY1 PY2 Line of Business / Period QO’s Primary Impact on Hospital Days

  29. Better Hospice Usage-ALOS Average Length of Stay in Hospice (Days) 50 45 40 35 30 25 44 35 39 34 32 36 20 15 10 5 0 Customer A Customer B Customer C Customer D Customer E Customer F QO Goal = 30 Days Medicare Hospice ALOS for cancer = 18 Days

  30. Client A: Feb ‘99 – Jan ‘02 $10,000 $9,000 $8,000 Average Annual Cost per Cancer Patient $9,329 $8,884 $7,000 $8,713 $8,524 $6,000 $5,000 PY1 PY2 PY3 Baseline Adjusted Using Cancer Cost Inflation per Milliman USA Three Year Net Savings: $16+ million

  31. Client C: Sept ‘99 – Aug ‘01 $12,000 $11,000 $11,301 $10,000 $11,107 $9,111 $9,000 $10,043 $8,000 $7,000 PY1 Adjusted* PY2 Adjusted* Baseline *Program Administrative Costs Included and Inflation Adjustment per Milliman USA Two Year Net Savings: $1.5 million

  32. Physician Satisfaction

  33. Patient Satisfaction Scores The QO CM** provided me with meaningful information about my cancer and its treatment. Q1 The info from the QO CM helped me make informed decisions about the care received. Q2 The QO CM talked to me about the common side effects of my cancer treatment. Q3 My QO CM talked to me about how to get medical help for side effects if needed. Q4 2000 Data I felt my individual needs and preferences were taken into consideration. (Program Year 2) Q5 QO helped me with the coordination of care associated with my illness. Q6 1999 Data I had good advice from the QO CM on where to find help in the community. (Program Year 1) Q7 The QO CM responded to my phone calls in a timely fashion. Q8 Contact with the QO CM helped me to better understand my health care benefits. Q9 QO is a valuable part of my health care benefit. Q10 Overall, I was satisfied with the Cancer Care Program. Q11 1 2 3 4 5 Strongly Disagree Agree Strongly Agree Disagree Neutral Average Score per Question Results are from an actual QO client in an established market. Over 500 surveys were mailed over the two years, generating a 37% response rate (versus a targeted response rate of 30%). CM = Care Manager or Care Management

  34. What Do Patients Say About QO?

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