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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. - PowerPoint PPT Presentation
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Oncology OutcomesIntroduction 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
240% Variation (FN)
Tampa Prostatectomy:
1.0/1000 men
St. Petersburg:
3.4/1000 menSource: Wennberg, J. Dartmouth Atlat of Health Care (1998)
DadeMonroe
Broward
Palm Beach
Martin
St. Lucie
Glades
Highlands
Lee
Charlotte
Sarasota
PinellasHillsborough
Pasco
Hernando
CitrusLake
Orange
Seminole
Volusia
Duval
ClayBaker
Brevard
PolkOkeechobee
6
8.51
7.81
Prostatectomy: High Volume Caseload Better
Lower risk of readmissions
Serious complications
Lower risk of mortality within 30 days
High volume correlates positively with:
N = 101,604
8.2%
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
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
Patient Issues Regarding End of Life
Dying in America, Last Acts’ 11 Committees, Nov 2002
8
DoCoordinate
Don'tCoordinate
Part of MyRoutine
Not Part of MyRoutine
88.4% 43%
Poll of 800 Oncologists in the European Society of MedicalOncologists, surveyed in July 2002 by N Cherny, MD
Theoretical Actual
Coordination of End of Life Care
9
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
Today’s Unmanaged Cancer Physicians
10
Communication About Death With Patient
23%
37%
40%
Physician overly optimistic in projecting likelihood and date of death
Physician levels honestly with patient
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
34% 38%41%
43%
62%
Lung Genito-
urinary
Gastro-
intestinal
Breast Lymphoma
Cancer Patients Receive Inadequate Analgesia
N =522
13
Summer 2000:
Dot Com BombingAl vs. George
BCBSRI Decides to Act
14
BCBS of Rhode Island ProjectBCBS Membership vs. Other Health Plans
Higher prevalence
More inpatient use
More short stays that could be averted
Much greater ER use
Program ExpectationsMove chemo out of hospital
Increase hospice use and LOS
Avert unnecessary ER visits
15
Commercial Cancer PrevalenceCommercial Cancer PrevalenceCommercial Cancer Prevalence Comparison:
85% Higher than Repository
6.9
12.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
BLUE CHiP: 1999 LifeMetrix RepositoryCan
cer
Pat
ient
s pe
r 1,
000
Mem
bers
pe
r Y
ear
1999 Blue CHiP data: 625 Malignant Cancer Patients out of 49,082 Commercial HMO members.
16
Hospital Use - CommercialHospital Use - Commercial
Commercial Acute Hospital Days/1000 Comparison: 87% Higher Than Repository
38.3
20.5
6.2
3.6
0.0
2.0
4.0
6.0
8.0
BLUE CHiP: 1999 LifeMetrix Repository
Acu
te A
dmits
/100
0
0.0
10.0
20.0
30.0
40.0
50.0
Acu
te D
ays/
1000
Acute Cancer Days/1000 per Year Acute Cancer Admits/1000 per Year
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
0%
5%
10%
15%
20%
25%
30%
<= 2 3-4 5-7 8-10 11-15 16 to25
> 25
LOS Ranges (# of Days)
Distribution of LOS for all Blue CHiP Members
18
ER Visits - CommercialER Visits - CommercialCommercial Emergency Room Visits/1000 Comparison:
3.2 Times Higher than Repository
0.86
3.63
0.00
1.00
2.00
3.00
4.00
BLUE CHiP: 1999 LifeMetrix RepositoryER
Vis
its
pe
r 1
,00
0 M
em
be
rs p
er
Ye
ar
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 programWidely 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
Treatment Authorization Guidelines
Telephonic Nurse Care Management
Integrated Care Management System
Data Analysis
24
Outsourced Telephonic Care Management
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
25
Anticancer Treatment Palliative Care
Diagnosis
Psychosocial Counseling
Nutrition Services
Pain Management
Fatigue Management
Cancer Rehabilitation
Advanced Care
Planning
Hospice Referral
Ongoing Symptom
Management
Attack Cancer Aggressively
Supportive CareQO
Communication About Values With Patient
Unmgd
< 1 Month
Attack Cancer Aggressively
Pain Management Hospice
Referral
Diagnosis
26
60%
25.2%
11%
3.6%0.2% Recommend not to authorize
Ruled out by stratification criteria
Plans approved
Data discrepancies
Peer to peer Discussions
Cancer CasesCancer Cases 1% of Commercial Membership
QO’s Historical Experience with Treatment Plan Reviews
27
Savings by Category
Coordination of End of Life
Chemo/Rad Cost Savings
Averted ER Visits
Reduction in Readmits
Management of Complication Rates
Areas of Impact
QO’s Primary Impact on Hospital Days
2.792.68
2.48
3.51
3.04 3.00
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Commercial: Baseline
Commercial: PY1 Commercial: PY2 Medicare Risk: Baseline
Medicare Risk: PY1
Medicare Risk: PY2
Line of Business / Period
Acu
te H
osp
ital
Day
s p
er C
ance
r C
ase
29
39 34 44 32 36 35
0
5
10
15
20
25
30
35
40
45
50
Customer A Customer B Customer C Customer D Customer E Customer F
Average Length of Stay in Hospice (Days)
QO Goal = 30 Days Medicare Hospice ALOS for cancer = 18 Days
Better Hospice Usage-ALOS
30
Adjusted Using Cancer Cost Inflation per Milliman USA
$9,329 $8,884$8,713$8,524
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
Baseline PY1 PY2 PY3
Av
era
ge
An
nu
al
Co
st
pe
r C
an
ce
r P
ati
en
t
Three Year Net Savings: $16+ million
Client A: Feb ‘99 – Jan ‘02
31
$11,301
$9,111$10,043
$11,107
$7,000
$8,000
$9,000
$10,000
$11,000
$12,000
Baseline PY1 Adjusted* PY2 Adjusted*
*Program Administrative Costs Included and Inflation Adjustment per Milliman USA
Client C: Sept ‘99 – Aug ‘01
Two Year Net Savings: $1.5 million
32
Physician Satisfaction
Question Average Score
PY1 PY2 PY3
QO's CM Staff is courteous and helpful. 4.12 4.20 4.25
QO's CM Program is easy to work with. 3.79 3.95 3.96
QO's CM Staff answer the phone in a timely manner. 3.75 3.89 3.98
QO's CM Staff return phone calls in a timely manner. 3.70 3.77 3.85
Info requested from QO regarding my patient(s) is conducted professionally. 4.22 4.20 4.26
Answers to an urgent referral are obtained from QO promptly. 3.76 4.03 4.06
Obtaining authorizations from QO for my patient(s) is timely. 3.66 4.00 3.94
Our office communicates successfully with QO via fax transmission. 3.91 4.04 4.10
The Orientation provided by QO's PR reps was informative. 3.76 3.81 4.09
QO's PR reps conduct themselves professionally. 4.08 4.27 4.37
Overall, you were satisfied with the interactions you had with QO. 3.85 4.00 4.10
3.86 4.00 4.09
33
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
1 2 3 4 5
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
Q10
Q11
2000 Data(Program Year 2)
1999 Data(Program Year 1)
Strongly Disagree Disagree AgreeNeutral Strongly Agree
The QO CM** provided me with meaningful information about my cancer and its treatment.
The info from the QO CM helped me make informed decisions about the care received.
The QO CM talked to me about the common side effects of my cancer treatment.
My QO CM talked to me about how to get medical help for side effects if needed.
I felt my individual needs and preferences were taken into consideration.
QO helped me with the coordination of care associated with my illness.
I had good advice from the QO CM on where to find help in the community.
The QO CM responded to my phone calls in a timely fashion.
Contact with the QO CM helped me to better understand my health care benefits.
QO is a valuable part of my health care benefit.
Overall, I was satisfied with the Cancer Care Program.
Average Score per Question
Patient Satisfaction Scores
34
What Do Patients Say About QO?
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