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Evolving the Oncology Medical Home• Dr. Michael Kolodziej, National Medical Director,
Oncology Solutions, Aetna• Kathy Lokay, President and CEO, Via Oncology• Barry Russo, CEO, The Center for Cancer and Blood
Disorders• Maria Sipala, Director, Strategic Planning, National
Network Contracting, Aetna• Amy Supraner, Strategic Planning Manager, National
Network Contracting, Aetna• Dr. Ira Klein, National Medical Director, Clinical
Thought Leadership, Aetna
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We, too, can evolve further!
In the Beginning, a study: ↑ Adherence to EBM had ↓ cost with no negative impact on treatment efficacy
– Study: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting” (NSCLC)
– Published: Journal of Oncology Practice (American Society of Clinical Oncology Peer Reviewed Journal), 1/19/2010
No change in overall survival between the study groups
Source: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting”. Journal of Oncology Practice. January 2010. Volume 6. No.1. p 12-18
Significantly lowered cost in the case group vs. The control group
Purpose: Evaluate the cost effectiveness of evidence-based treatment pathways for NSCLC patients
Conclusion: Results of this study suggest that treating patients according to evidence-based guidelines is a cost-effective strategy for delivering care to those with NSCLC.
Overall survival by Pathway status.
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We All Derived a Similar Equation Regarding Cost and Efficacy in Cancer Care
V = Q
C
• Guideline Based Therapies
• Targeted Impact• Low Toxicities• Improved Survival• Improved QOL
• Best Supportive Care• Avoidance Hospital Days• Avoidance ED Visits• Site of Service Costs ↓• Medically Unnecessary
Care ↓ at EOL
Aetna Developed a Payer Strategy around this, and so did everyone else…..but not all the same
• Drive efficient use of evidence-based medicine– platform that provides content and workflows– integrate into the Aetna and provider systems – simplify the administrative processes for providers
• Avoid waste and misuse of medical services – better provider alignment
(e.g., Oncology Patient Centered Medical Home), – better network (narrow, tiered)– better decision support strategies
• Leverage and integrate the many current (and future) medical and pharmacy cancer-care initiatives
– seamless, end to end cancer experience for Aetna members and providers
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Who’s got Clinical Decision Support (CDS) available in the Marketplace?
Where Aetna has been with “pilots” in order to prove out theoretical concepts:
Can CDS tools alone, without other inducements beyond minimal workflow improvements, influence NCCN guideline compliance in all pop., no additional economic incentives?
Do Pathways tools (clinical decision support, or CDS) + oncology medical home resources make economic sense, contract in commercial pop.?
Will CDS tools and medical home resources and tight healthplan linkages and reporting improve value parameters in Medicare pop., blended contract?
Can CDS tools alone + altered drug fee schedules improve value parameters, pay for value contract, all pop.?
2010 2011 2012 2013
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TX Oncology pilot Cardinal/P4 pilot Eviti pilot TX Oncology pilot, #2
FFS payments to physicians
Total physician payment
All other payments
Current Model Proposed Model
Current Model Proposed Model
To
tal
ph
ys
icia
np
ay
me
nt
All o
the
rC
an
ce
r ca
reS
pe
nd
ing
e
lem
en
ts
FFS payments to physicians
Care coordination feeCase management payment
Payment for all other cancer carePayment for all other
cancer care
Waste and inefficiency Waste and inefficiency
The Goal is to Achieve Meaningful Payment Reform
The Brookings Institution, Washington, D.C.
Next Step: the Oncology Medical Home
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What’s Needed for Practices to meet the Aetna Criterion for OMH Contracting:
Market level conditions
Practice Volume
Oncology Medical Home Solution
Practice IT & other capabilities
40-50 Aetna Breast, Lung, Colorectal Cancer patients and $500-600K per year spend on them.
Must use Clinical decision support tool.
Perform enhanced triage, both telephonic and in-office
Nurse Navigator.
Can conduct and collate results of a patient satisfaction survey.
Can do PDCA style quality improvement program.
Membership in Market. Market buy-in. Is there a mandatory
CDS program in state? Is practice in ACO/PHO?
Infusion Suite in office (buy and bill model) vs. sending to outpatient infusion center.
Aetna Oncology Medical Home payment for oncology care means growth instead of shortfall
Sustainable Future
Performance
*Ultimately, this becomes
a better “reset”
baseline for episodes and/or bundles
Current Fee for Service
ModelInvest in
New processes
Shared Savings on
improvement from
baseline outcomes
Enhanced drug fee schedule
Changes in pre-cert
model alter FTE’s
S-codes for quality
processes that have meaningHIT Office
workflow efficiencies
*Diagram is illustrative and for discussion purposes only
Our goal is to create a sustainable business model designed around new sources of value that will be resilient through and post health care reform.
Growth
Future Base Model(s) Without Medical
Home-like contracts
Revenue Gap(e.g., private payer and
CMS induced)
Practice Demographics Market Benchmarks
Savings Calculations
Aetna Shared Savings Practice Shared Savings
Reconciliation: Practice, Market Level Benchmarks, Financials
The Future: Move Providers up the Value Chain with multiple support effortsVendor based programs introduce Clinical Pathways and Measure Adherence along with Quality Measures
More sophisticated Practices move from vendor based Clinical Pathways programs to Oncology Medical Homes (OMH)
Smaller Practices work with Education Oncology programs such as NJ ION program
Create episode and bundling methodology test with OMH, as well as deployed in ACO
Provider engagement Index
Low Touch High TouchSome Clinical Engagement
OMH deployed in 65% of markets and ACOs by 4Q15
More Clinical Engagement
High Clinical Engagement
Cardinal, New Century Health, Innovent