Transcript Session Title - Alice Gosfield

Oncology Patient-Centered
Medical Home®
Business Case for Quality
Value Based Hematology and Oncology Care
John D. Sprandio, M.D., FACP
Consultants in Medical Oncology & Hematology, P.C.
Oncology Management Services, LLC.
Philadelphia, PA
Agenda
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Rocket Science, Physician role, PCMH, Cancer
Performance Measurement
Oncology PCMH Model
Results
Replication
Stakeholder Perspective
Summary – it’s not just about cancer
Rocket Science
Physician’s Central Role
Primary PCMH
Focus on Cancer Care
What’s Wrong with the US Health
Care Delivery System?
Continuum of health care science
Basic science – unravels mysteries
Translational research – develop new treatments
Policy analysts – measure outcomes
Fundamental Question: How is care best delivered?
Dartmouth Center for Health Care Delivery Science
“The real rocket science now in health care
is cost and quality.”
Dr. Jim Yong Kim
US Health Care
Focus on Cost:
2012 health care costs $ 2.8 trillion
Taken alone = the worlds 5th largest economy
We outspend the rest of industrialized world
90% on rescue, 10% on chronic care verses 50/50
Targeting waste due to failures in:
Delivery
Coordination
Overutilization
Pricing
Administrative burden
Fraud
Focus on Quality: Legislation, Regulation, Enforcement,
Policy Development, Market Demands
Doing Well by Doing Good:
Improving the Business Case for Quality
Gosfiled, Reinertsen, et al. 2003
Physician engagement is essential in driving quality
Centrality of doctor-patient relationship:
• Most personal & critical interaction that defines healthcare
Explanation, prediction, plan of care
• Physicians have a broadest scope of professional jurisdiction
Drive the provision of all goods and services
• Patient experience based on one-on-one relationship
• Physicians are the patient portal to the rest of the system
Referrals, education, interpretation of insurance benefits
Doing Well by Doing Good:
Improving the Business Case for Quality
Gosfiled, Reinertsen, et al. 2003
Barriers to quality = physician “time stealers”
Incentives, EMR, work-flow, decision support, niche
competitors, documentation & coordination systems,
outcome targets, real-time performance measurement,
lack of defined PC team based model
Physician work environment redesign
Standardize
Simplify
Make clinically relevant
Engage patients
Fix accountability at the locus of control
Primary Care Focused
Case for Quality & Value
Patient Centered Primary Care Collaborative
• 40 year old concept: ACP, AAFP, AAP, AOA
Partnership with personal physician,
coordinating/integrating/documenting care, promotion of quality
& safety, enhanced access, whole person orientation, reduced
acute events, reduced utilization, and improved outcomes
• NCQA emerged as one standard setting entity
9 Standards
3 levels of recognition
• Improved Value reported 2010 and 2012
Reduced cost
Improved clinical outcomes
Improved patient and provider satisfaction
(Grundy, et al)
Era of Health Care Reform
Transitioning from Volume to Value
Value = quality/cost
Enhance Quality by Increasing reliability of delivery
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Focus on execution (processes) of care delivery
Incorporation of High Reliability Principles
Control Cost by Reducing unnecessary utilization
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Unnecessary utilization = waste
Failures of delivery, coordination, overtreatment
Demonstration of results
Data transparency, accountability, rapid learning
Focus on Cancer Care
• Microcosm of the US health care system
High technology
Expensive new drugs
Fragmented care
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1.6 million Americans diagnosed with cancer annually
Direct costs exceeded $126B in 2010
0.69% of Commercially insured population
11-12% of Commercial health care spend
Medicare responsible for > 50% of patients
Fastest growing cost area in medicine
Focus on Cancer Care
• Foundation of medical home and accountable care
organizations has been primary care oriented
• Complex care outside the scope of primary care requires
delegation to specialists (cancer, nephrology, etc.)
• How does the Primary PCMH or ACOs manage cancer
costs if the patient is transferred to oncology?
• Oncology Patient-Centered Medical Home® (OPCMH)
model has generated broad interest following recognition
by NCQA in 2010
• Oncology PCMH projected to reduce cancer spend
Era of Cancer Care Reform
Provider Accountability
“Only those giving the care can improve it”
Failure to control cost (waste, site of care)
• Diminishes Value
• Results in further funding cuts
• Unintended clinical consequences for the most vulnerable
• Reduced access, increased co-pays, reduced compliance
Standardization of delivery = waste reduction
• Chemotherapy guidelines & pathways
• Care delivery beyond chemotherapy selection
• Requires practice transformation
Improving the Business Case for Quality
CMOH 2003-2013
Principles of re-designing cancer care delivery:
• Standardize/Streamline (variation in process of care)
• Simplify payment and administrative systems
• Minimize clinically irrelevant physician activity
(Make complex decisions & maintain personal relationships)
• PCMH (engage, educate, access, coordination)
• Accountability at physician-patient locus (care team)
• Ongoing data driven process improvement
CMOH: 2009 – 2013
Making a Business Case for Quality
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Focus on demand to improve quality and value
Led to development of OPCMH model
NCQA PCMH recognition & QOPI certification
Opportunity to lead positive change
Prepare for future payment models
• Episode based, bundles, budgeted payment system
Prepare for future organizational structures
• ACO, Hospital System/Payer hybrids, independent practices,
large single TIN networks, Clinically Integrated Networks, etc
Lessons from Medicare
Demonstration Projects
CBO Issue Brief January 2012
6 Disease Management & Care Coordination
Demonstrations
Goal: Improve the quality of care for costly, chronic illnesses
In nearly all 34 programs spending was unchanged or increased
All had 3rd party care management vendors involved
Number of programs focusing on cancer care – none
4 Value-Based Payment Demonstrations
Goal: Improve quality and efficiency via financial incentives
1/4 bundled payment programs resulted in 10% Medicare savings
Successful program operated at a loss
Number of programs focusing on cancer care – none
Lessons from Medicare
Demonstration Projects
CBO Issue Brief January 2012
Take Home Message
Changes in payment & delivery systems are necessary
Timely data on use of care (potentially avoidable complications)
Focus on transitions of care (Hospital discharge; primary to specialist)
Physician-led team-based care (physician, nursing, navigators)
Integrate management systems (minimize vendors)
Target high-risk patients – predictive modeling
Rigorous design, concrete answers facilitates rapid learning cycle
Potential for successful re-designing care delivery in oncology
Physician-lead Care Management Team + Patient engagement
Promotion of Physician Accountability at the point of delivery
Timely data driving a rapid learning cycle
Performance Measurement
The Four Habits of
High-Value Health Care Organizations
Everyone believes they are delivering “high quality,
highly reliable care”
• Specification and Planning
• Micro-system design
• Measurement and oversight
• Commitment to ongoing process improvement
Richard Bohmer, M.B.,Ch.B. NEJM 12/1/11
Internal Perception
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Measured Reality
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“Eminence Based
Medicine”
Providing sub-optimal
medical care with
increasing confidence over
an impressive number of
years.
~British Medical Journal, Vol. 1 Sept 2001
© Kaufman Strategic Advisors, LLC
Strategic Goal
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How can a physician-led care team reliably deliver
cancer care?
Critical Provider Solutions
• Standardized process of
care and data collection
• Presentation of consumable
data, decision support –
with each patient
interaction
• Documentation tools to
relieve the burden on a
physician’s ability to
execute care consistently
• Standardized
communication
• Real time performance data
IRIS Software Suite
Physician-Centric Software
Enabling Patient-Centered Care
• Clinical Decision Support System (CDSS)
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Work-flow integrated with delivery, documentation & MU
Speech-recognition integrated into work-flow
Immediate document completion and auto-dissemination
Physician performance reports
Physician document and lab management review
Longitudinal performance status & NCI graded symptom tracking
Triage outcomes & Unscheduled visit tracking
Personalized Patient Assessment and Verification Tool
Enhanced Patient Queuing/tracking program
Individual patient test result and appointment tracking
Screening and Immunization prompts
Portal access for patients and referring physicians
Palliative and End-of-Life Care Management prompts
Enables PCMH-N functionality
Quality, Service & Delivery Parameters
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ASCO - QOPI standards
NCCN Guidelines
American College of Surgeons
NQF, NCPF, NCCS, ONS
CMS - PQRS, e-Rx
NCQA – PPC-PCMHTM
OPCMH – services
Institute of Medicine
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2012
Ensuring Quality Cancer Care
Improving Palliative Care for Cancer
From Cancer Patient to Cancer Survivor: Lost in Transition
Assessing & Improving Value in Cancer Care
Best Care at Lower Cost
Oncology PCMH Model
Oncology Patient-Centered Medical
Home® Model
Re-engineered Process of Care & Coordination
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Ownership of all aspects of cancer care delivery
Focus on patient needs and evidence-based care
Reduction in unnecessary variation & resource utilization
Enhanced communication with PC PCMH & Specialists
Real-time physician/practice performance measurement
• Continuous process improvement
• Encourages Clinical Integration between practices
Oncology Patient-Centered Medical
Home® Based on NCQA PPC-PCMHTM
NCQA Standards drive Quality, Service & Utilization
• Enhanced Access & Continuity
• Identify and Manage Populations
• Plan and Manage Care
• Self-care Support & Community Resources
• Track and Coordinate Care
• Measure and Improve Performance
Process Measurement
Rapid Learning Cycle
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Function of mutually reinforcing care-team
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Merging Work-Flow & Clinical Decisions
Guidelines, staging, screening, prevention
Triage & Symptom Management algorithms
Communication/Documentation turn around
Patient Navigating/tracking tests & referrals
Performance Status & Palliative Care tracking
End of life care/promoting shared decisions
Patient & Physician portal utilization
Management of at risk populations
Interdependent roles, responsibilities, and hand-offs
Patient & Payer Centered
Outcome Measures
Patient Experience
• AHRQ CAHPS: Consumer Assessment of Healthcare Providers
and Systems
Outcomes
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Staging compliance
Chemotherapy guideline adherence
Emergency Room evaluations
Hospital admissions / length of stay
Outpatient visit reduction
End of Life Care parameters
Diagnostics: imaging & laboratory
Results
NCQA PCMH & The Four Habits of
High-Value Health Care Organizations
“The ability to disseminate and deliver high value clinical innovation is
based on similar, portable habits of care management …
implemented simultaneously” Richard Bohmer, M.B.,Ch.B. NEJM 12/1/11
• Specification and Planning
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Merging operational and clinical decisions with documentation
• Micro-system design
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Matching subpopulations and pathways, triage algorithms
• Measurement and oversight
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Targeting internal operational issues – drive outcomes
• Commitment to ongoing process improvement
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Insights for better outcomes fuels modification of Specification and Planning
USON/Milliman: Approximately 1 hospital
admission per chemotherapy patient per year
(n=14 million commercially insured; 104,473 cancer patients)
Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
Average emergency room (ER) Evaluations per chemotherapy patient per year (APCPPY)
for the CMOH patient population , 2004-2011.
3.000
2.600
USON/Milliman: Approximately 2 emergency
room visits per chemotherapy patient per year
2.567
2.500
ER Evaluations per chemotherapy patient per year
(n=14 million commercially insured; 104,473 cancer patients)
2.067
Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
2.000
1.604
1.500
1.273
1.119
1.000
0.910
0.818
0.500
0.000
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Year
2009
2010
2011
Guideline & Pathway
Adherence
Chemotherapy care plans are NCCN compliant
Deviation requires customization (controlled)
Physician selects care plan within EMR
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Selection shared with billing and nursing staff
NCCN Compliance
Adjuvant and first line metastatic
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Adherence > 95% 2007 – 2010 (practice)
Individual physician performance followed
Pathway Compliance
Small number of patients > 80%
OPCMH End-of-Life Care
Collaborative
Dartmouth
OPCMHTM
QOPI
Death in hospital %
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PH numerator; denominator ?
Practice*
Hospital admissions, last 30 days, %
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X
PH numerator; denominator ?
Practice*
ICU admissions, last 30 days, %
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X
PH numerator; denominator ?
Practice*
ICU Days, last 30 days
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X
PH numerator; denominator ?
Practice*
ChemoRx, last 30 days
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X
Hospice, last 30 days, %
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X
PH numerator; denominator ?
Practice*
Hospice days, last 30 days
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X
PH numerator; denominator ?
Practice*
Hospice within 7 days of death, %
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X
X
PH numerator; denominator ?
Practice*
Hospice enrollment, %
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X
PH numerator; denominator ?
Practice*
ACP discussion with metastatic disease
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X
PH numerator and denominator
Advanced care plan documented, %
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Practice
ECOG performance status documented
at each visit
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Practice
X
Measure
PH numerator; denominator ?
Practice*
OPCMH End of Life Care
• Performance Status Driven
Influences ongoing treatment decisions
Standardized assessment & longitudinal tracking of PS
Impact of disease & therapy on abilities, QOL
Auditing for PS decline (ECOG 3)
Ongoing Discussion of Goals of Therapy
Documentation at onset of stage IV disease
Documentation of ongoing discussion with decline in
PS, change in therapy
Goal: Promote shared decision-making
End of Life Care
Data
• Hospice Average Length of Stay:
2009:
2010:
2011:
26 days
32 days
35 days
34% increase
• Place at time of death:
70% home 2010
74% home 2011
• ER visits & hospital admissions last 30 days of life:
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2010:
2011:
2010:
2011:
39.3%
36.4%
23.8%
20.1%
total
total
total
total
practice
practice
practice
practice
Admissions
Admissions
ER visits
ER visits
Oncology PCMH
Impact on Cost of Cancer Care
Projected % Reduction in Cancer Care Cost
1-3
Chemotherapy pathways program
4-6.3 Inpatient hospitalizations (5-25% reduction)
.6-1.1 ER evaluations (20-40%)
.1-.4 Diagnostics
.9-1.9 End-of-life care coordination
Total 6.6 – 12.7 % reduction
Annual cancer “spend” $125B = $8-16B savings
Adapted from international consultants evaluation of OPCMHTM application to cancer care
Replication
Replication of the Model
Four Key Steps
Specialty societies define quality parameters
• ASCO, ACOS, NCCN, COA, NQF, NCPF
NCQA Specialty Practice Recognition Program
• Application of PCMH principles to specialties
• Specialty Practice standards March 2013
Payer engagement and support
• Regional and national payers
Phases of construction of PC-SP
• Payer Incentives & Practice Deliverables defined
NCQA PC-SPR Transformation vs
other Quality Improvement models
NCQA Standards are based on:
Service, quality, utilization, meaningful use
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Standardized processes across practice
Re-defined roles - supporting a physician-led team
Promotion of physician efficiency & accountability
Applicable to Oncology, Nephrology, Cardiology,
Rheumatology
Level of Oncology Accountability
Models for Payment of cancer care
FFS
Pathways
OPCMH
Bundled or
Episode
Payment
Oncology Patient-Centered Medical
Home® Value Proposition
• OPCMH – clinical & business methodologies
– Data driven practice/patient care efficiencies
– Community and hospital-based practices
• OPCMH - organizational construct
– Oncology “plug-in” to PCMH as a PCMH-N
– Establishes care management accountability
– Communication that bridges specialists and PCMH
• OPCMH – as PCMH bridge
– Aligns oncologists for ACO, Clinical Integration, etc
– Platform for pricing bundles, episodes, etc or episode of
care payment
Stakeholder Perspective
Patients & Payers Want Reliable
Patient-Centered Services
• Personal relationship with a physician
– Explanation, Prediction, Plan of intervention
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“On demand” access to care & information
Total coordination of all aspects of care
Communication among all providers of care
Best possible outcomes
– Improvement & preservation of quality of life
– Fewer complications, ER, hospital admissions, visits
• Fewer co-pay related events
– Rational care at the end of life
Summary
• Foundation of PCMH and ACOs are primary care oriented
• Costly care exists outside the scope of primary care
• Primary care delegates management of complex care
(cancer, nephrology, etc) to specialists
• The specialty community has the capacity to dramatically
improve care and reduce costs
• This requires practices to transform the way they
deliver care, which requires stakeholder collaboration
• Payers need to promote physician driven efforts to
enhance value & continuously improve care delivery
Questions
For more information about Oncology Patient
Centered Medical Home:
John Sprandio
Susan Tofani
[email protected]
[email protected]
www.OPCMH.com