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Oncology’s Role In Population Health Ira M. Klein, MD, MBA, Janssen Pharmaceuticals Robert Kropp, MD, Aetna Harlan Levine, MD, City of Hope Kavita Patel, MD, Brookings Institution Kelley D. Simpson, Oncology Solutions LLC Presentation Map Kavita Patel, M.D., MS, Managing Director for Clinical Transformation & Delivery Engelberg Center for Health Care Reform Studies Brookings Institution Kelley D. Simpson, Senior Partner Oncology Solutions, LLC Practical Application Present & Future Trends Robert Kropp, M.D. Regional Medical Director, Aetna AMC’s Role in PHM Accountable Care Solutions Triple Aim Harlan Levine, MD Chief Executive, City of Hope Medical Foundation Associate Director for Community Initiatives Comprehensive Cancer Center Ira Klein, MD, MBA, FACP Senior Director, Health Care Quality Strategies Johnson & Johnson Health Care Systems Inc. 1 Including Oncology in the Triple Aim Goals of Care Ira Klein, MD, MBA, FACP Senior Director, Health Care Quality Strategies Johnson & Johnson Health Care Systems Inc. 4 Today, still mostly in a FFS world Fundamental change requires increased collaboration and aligned incentives for oncologists re-organize into population health management PPO Today Performance based networks PatientCentered Medical Home Institutes of Quality Accountable Care Organization Tomorrow Broad-based access to care delivery Total population health management All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson 5 Private Market ACO formation matches CMS goals to address population health management SGR fix/MACRA Triple Aim Goals Insightful Analytics Measureable Clinical Outputs ACO Management Plan Pop. Health in a new APM World All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson 6 The NQS approach to guide efforts to improve health and the quality of health care 3 Goals 6 Priorities Performance Programs Payers Providers Hospitals/IDNs ADOPT FOCUS INCENTIVIZE Provide better, more affordable care for the individual and the community Guide efforts to improve health and health care quality Incentivize stakeholders through Accountable Care Organizations (ACOs) and Bundled Payments All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson 7 NQS “Priorities” represent 6 quality domains used by CMS to drive value based care Priority/Domain Clinical Care Definition Sub-domains Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease • Appropriate Use • Clinical Outcomes/Intermediate Outcomes • Medication Adherence • Patient Reported Outcomes • AHRQ CAHPS – Patient Experience of Care • Shared Decision Making • Care Plan Creation • Patient Activation Patient Experience Ensuring that each person and family members are engaged as partners in their care Population/ Community Health Working with communities to promote wide use of best practices to enable healthy living • Screening/Preventive Services Making care safer by reducing harm caused in the delivery of care • Health Care Acquired Conditions • Potentially Avoidable Complications Patient Safety Care Coordination Total Overall Costs Promoting effective communication and coordination of care Making quality care more affordable for individuals, families, employers and governments by developing and spreading new healthcare delivery models • Communication of Care Plan • Hospital Readmissions • Medication Reconciliation • Global/Capitated Costs/Medicare Spending Beneficiary • Episode of Care Costs for: - Acute & 3 - Chronic Conditions 3 All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson 8 The ACO Management Plan for Cancer Care: Population Health based Oncology Activities Objectives: • Analyze the cancer population characteristics • Analyze the cancer medical cost spend • Analyze the medical quality and cost improvements in key measures that would be needed to sustain the business model Tools: • Efficiency Modeling from Oncology Solutions • Sections include: – Demographics – Disease specific profiles – Outlier profiles – Costs by type of service – Inpatient Detail – Inpatient by Admit Type – ER – Radiation Oncology – Outpatient procedures – Lab – Radiology – Pharmacy – Hospice/Palliative care • Have an Efficiency Model Tab: – What If scenarios for variable degrees of improvement in utilization – Benchmarks against national best in class, industry or size/demographics/risk comparison groups. All statements made today should be interpreted as personal views and do not represent views of Johnson and Johnson Health Care Systems Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson 9 Accountable Care Solutions from Aetna Robert Kropp, M.D. Regional Medical Director, Aetna 10 The Academic Medical Center’s Role in Population Health Harlan Levine, MD Chief Executive, City of Hope Medical Foundation Associate Director for Community Initiatives Comprehensive Cancer Center 18 Academic Medical Center’s Role in Population Health Basic Science & Discovery Research & Teaching Drive Next Generation Care Protocols Complex, Highly Technical Services Patient Centered Coordinated Care survivorship primary care system end of life, palliation Specialty Population Health Population Health Oncology • Narrow Networks • Primary Care • Personal Accountabilities & Behaviors Some fit, but differences: High cost, uncommon, moderate complexity High cost, rare, highly complex Rapid changes in standard of care Niche expertise matters Accountable Health System Academic Medical Center Obligation • Deliver care cost effectively • Advance the field Health System Obligation • Allow access to expertise • Compensate based on complexity Joint Accountability • Coordinate patient care • Measure outcomes that matter Challenges that must be overcome • Deploying rational risk bearing models – Risk assumption not created for low frequency, high cost events – Case rates are problematic when there is high variability in cost • Acknowledging that Treatment and Diagnostics are evolving and fall into three categories: Proven, Unproven and Common Sense • Defining the optimal care model: Tension between bundling and fragmentation of care • Managing the high cost of medications • Identifying measures that matter—Value~Outcomes/(Cost X Time) Present and Future Policy Trends in Population Health to Oncology Care Kavita Patel, M.D., MS, Managing Director for Clinical Transformation & Delivery Engelberg Center for Health Care Reform Studies Brookings Institution 23 Practical Application of Oncology-Specific Tools Kelley D. Simpson, Senior Partner Oncology Solutions, LLC 24 PHM Integration Challenges for Oncology • • • • • • Increasing difficulties with timely access to primary care providers—wait times for appointments can be months in many health systems The primary care provider pool seldom “rubs elbows” with oncology providers causing a divide of information exchange and knowledge transfer Primary care providers are managing ever-increasing patient populations and are expected to acknowledge the “latest and greatest” prevention, screening and diagnostic work-up guidelines for a range of diseases (and, by the way, there are 100+ different types of cancer) Collaboration with a range of oncology and oncology-related providers, both employed and independent, fractures care coordination Information/EHR data exchange presents great limitations, particularly with independent oncology providers but also within captive physician networks where IT interfacing/integration is often stymied Genetic profiling and testing standards as well as national screening guidelines are swiftly changing patient assessment procedures—in Dr. Levine’s context these are ”proven, unproven or common sense” Landscape of PCP Oncology-Related Involvement • • • • PCPs primarily involved with cancer screening and detection activities Post diagnosis, the patient is referred to the oncology team and the PCP falls out of the loop as time passes—many times it is up to the patient to ensure information exchange PCPs play mostly a comanagement role for comorbid conditions, treating depression and pain management Some trending to involve PCPs more actively in survivorship care J Gen Intern Med. 2009 Sep; 24(9): 1029–1036. The Role of Primary Care Physicians in Cancer Care Carrie N. Klabunde, PhD, corresponding author Anita Ambs, MPH, Nancy L. Keating, MD, MPH, Yulei He, PhD, William R. Doucette, PhD, Diana Tisnado, PhD, Steven Clauser, PhD, and Katherine L. Kahn, MD An Oncology Led Strategy • The cornerstone of population health management (PHM) is clinical decision making supported by evidence-based standards of care powered by real-time analytics – This philosophy is in direct alignment with the Oncology Care Model and Patient-Centered Oncology Medical Home but focused exclusively on the cancer/cancer-related patient population from prevention, screening and early detection through end-of-life and survivorship care planning • With respect to oncology populations, oncologists are considered the “primary care” physician so…how can this knowledge transfer support primary care providers within the PHM eco-system? • One of the most effective strategies employed is cross-pollination of primary care providers within oncology disease-specific Clinical Performance Groups (CPGs) that set pathways by disease across the full cancer care continuum—triage, screening, diagnostics, treatment and EOL or survivorship care – Oncologists’ vast experience managing high-risk populations within a multi-d, patient-centered model of care spanning years is of great benefit to any overarching PHM program Oncology-Specific Elements Influencing PHM • CoC Community Health Needs Assessment (CHNA) to address: – – – – – The cancer program’s community and local patient population Health disparities Barriers to care: patient-centered, provider-centered, or health system-centered Resources available to overcome barriers on-site or by formal referral Gaps in the availability of resources to overcome barriers • Cancer focused community outreach and screening initiatives • Clinical Performance Group alignment with primary care, resulting in tools to support an overburdened primary care provider pool • High risk population management • Survivorship care management Primary Care Participation Essential for Multi-D Lung Program Development 01 PCP Participation Within Lung Cancer Clinical Performance Group BASELINE ASSESSMENT AND GOAL IDENTIFICATION • Developed Community Needs Assessment in collaboration with Program Director and Registrar • Identified gaps in existing services and barriers to access • Developed goals for lung cancer education, screening, work-up and referral parameters PATHWAY DEVELOPMENT AND PCP INSIGHT • • • • • • Pathology Radiology Primary care Thoracic surgery Pulmonology Medical oncology • • • • • • 02 Radiation oncology Cancer care navigation Cancer program director Tumor registrar Clinical research IT and marketing reps • Participated in development of pathways: Clinical presentation and risk assessment Findings and follow-up Navigator intervention and PCP communication • Recommended avenues for PCP education/marketing and direct-to-consumer marketing • Identified tools needed to ”make life easier” for the PCPs LUNG CANCER TOOLS AND COMMUNICATION 03 • Helped draft and finalize LDCT screening materials Physician Preference Profile Form with reverse page outline of NCCN guidelines Lung cancer screening algorithm Navigator intervention and PCP communication algorithm Phone Scripting and Intake Form Lung cancer program dashboard/metrics Letter to targeted high risk patient population • Assisted with designing IT form in PCP network EHR • Communication plan for education to broader PCP network SAMPLE Lung Cancer Screening Algorithm SAMPLE Phone Scripting and Intake Form Date of Baseline CT: Age at Baseline: Occupation: Level of Education: Sex: Male Female Weight: Height: Do you currently smoke? Yes No SAMPLE Physician Preference Profile Form Comprehensive Lung Program Physician Preference Profile Ethnicity: History of Smoking: BMI: How many cigarettes smoked per day? Has a physician ever told you that you had COPD, emphysema, bronchitis, or pneumonia? Pneumonia Bronchitis Emphysema COPD If yes, which one(s)?: Have you ever had any type of cancer (excluding basal or squamous cell skin cancer? If yes, list type of cancer(s): Have any of your immediate family (parents, siblings or children) had lung cancer? Have you had prolonged exposure to second hand smoke? Yes No Yes No If you quit, has it been less than 15 years ago? What is the total number of years you have smoked? Date: Date of Birth: Yes No Yes No Yes No You have agreed to allow OHS to maintain a preference profile on record. This profile allows the OHS radiologists to schedule all necessary follow-up activities to complete a diagnosis for your patients. 1. You HAVE Date: agreed to allow OHS to keep a preference profile on record. Biopsy Percutaneous needle biospy Bronchoscopy SuperDimension iLogic bronchoscopy All of the above 3. To your knowledge have you been explosed to radon, silica, cadmium, asbestos, arsenic, beryllium, chromium, diesel No Yes fumes, or nickel?: or HAVE NOT 2. If my patient’s lung screening is ACR LungRADS category 4A, 4B, 4X, S or C, please proceed with the OHS Lung Screening Program’s standardized diagnostic work up to include as indicated and appropriate (check all that apply): If so, please explain: You may have exposure to especially hazardous chemicals if you have engaged in any of the following occupations. Please mark any that apply. Sandblasting Manufacturing Painter Printer Asbestos worker Uranium mining Drywall Bartender Metal worker Ceramic worker Masonry worker Chemist Truck driver Glass worker OMC Clinical Staff Review By: Please indicate your patient care preferences below. These preferences will be kept on record at all Olathe Health System Screening and Diagnostic locations to be utilized for any patients that you refer for lung screening. If you have any questions or wish to make any changes to these preferences, please contact the Nurse Navigator at OMC at (XXX) XXX-XXXX. Thank you for your participation with improving the quality and continuity of care provided to patients at OHS. Yes No Please check below any new respiratory symptoms that have appeared in the last 6 months: Shortness of breath Cough Coughing up blood Wheezing Primary Physician Name: Your preferences do not constitute an order set for additional views or tests. This information will be utilized to allow the Lung Nurse Navigator to streamline the process of contacting your office for an order and coordinating patient scheduling for follow-up procedures. If a consult is required, please choose from the below preferences for patient referral: a. You prefer your patient choose a pulmonologist or surgeon for consultation. b. Please call the primary care physician office for patient referral to a pulmonologist or surgeon. c. You prefer to have your patient see Dr. or pulmonology or surgical group for any necessary consult, if covered by the patient’s insurance. c.(i) If a consult is required and your preferred pulmonologist or surgeon is not available within a reasonable timeframe or is not covered by the patient’s insurance, you request to have your patient seen by: Dr. or if covered by the patient’s insurance. You prefer your patient choose a pulmonologist or surgeon/group for consultation. 4. You agree to allow: The Lung Nurse Navigator to provide normal findings to your patient. The radiologist to provide results of abnormal diagnostic tests to your patient. The pulmonologist or surgeon to provide results of any pathologic test to your patient. A Lung Nurse Navigator will be present to provide an understanding of the next steps in the process… OR You request the patient receive any abnormal or positive diagnostic test results from you, the PCP. References: Journal of National Comprehensive Cancer Network Volume 10, Number 2, February 2012. Lung Cancer Screening. Physician Signature: Date: SAMPLE Physician Preference Profile Form SAMPLE Physician Preference Profile Form Comprehensive Lung Program Physician Front Page: PCP Completion GUIDELINES FOR Reverse Page: NCCNNCCN Follow-Up Screening Guidelines Preference Profile Date: nd Primary Physician Name: 2 Screening Please indicate your patient care preferences below. These preferences will be kept on record at all Olathe Health System Screening and Diagnostic locations to be utilized for any patients that you refer for lung screening. If you have any questions or wish to make any changes to these preferences, please contact the Nurse Navigator at OMC at (XXX) XXX-XXXX. Thank you for your participation with improving the quality and continuity of care provided to patients at OHS. You have agreed to allow OHS to maintain a preference profile on record. This profile allows the OHS radiologists to schedule all necessary follow-up activities to complete a diagnosis for your patients. 1. You HAVE or HAVE NOT Biopsy Percutaneous needle biospy Bronchoscopy SuperDimension iLogic bronchoscopy All of the above Your preferences do not constitute an order set for additional views or tests. This information will be utilized to allow the Lung Nurse Navigator to streamline the process of contacting your office for an order and coordinating patient scheduling for follow-up procedures. If a consult is required, please choose from the below preferences for patient referral: a. You prefer your patient choose a pulmonologist or surgeon for consultation. b. Please call the primary care physician office for patient referral to a pulmonologist or surgeon. c. You prefer to have your patient see Dr. or pulmonology or surgical group for any necessary consult, if covered by the patient’s insurance. c.(i) If a consult is required and your preferred pulmonologist or surgeon is not available within a reasonable timeframe or is not covered by the patient’s insurance, you request to have your patient seen by: Dr. or if covered by the patient’s insurance. You prefer your patient choose a pulmonologist or surgeon/group for consultation. 4. You agree to allow: The Lung Nurse Navigator to provide normal findings to your patient. The radiologist to provide results of abnormal diagnostic tests to your patient. The pulmonologist or surgeon to provide results of any pathologic test to your patient. A Lung Nurse Navigator will be present to provide an understanding of the next steps in the process… OR You request the patient receive any abnormal or positive diagnostic test results from you, the PCP. Physician Signature: • • • Date: Nodule <6mm, LDCT in 12 mos. Nodule 6-8mm, follow up LDCT in 3 mos. Nodule >8mm PET/CT nd After 2 Screening • Nodule 6-8mm with no increase in size, follow LDCT up in 6 mos. No increase, then yearly. Increase in nodule at 6 mos., surgery • Nodules >8mm, likely not cancer, follow up LDCT in 3 mos. No increase, LDCT in 6 mos. No increase, then yearly. If increase at 6 mos., consider surgery • Nodule >8mm, maybe cancer, refer for biopsy or surgery agreed to allow OHS to keep a preference profile on record. 2. If my patient’s lung screening is ACR LungRADS category 4A, 4B, 4X, S or C, please proceed with the OHS Lung Screening Program’s standardized diagnostic work up to include as indicated and appropriate (check all that apply): 3. LUNG SCREENING nd 2 Screening • • • Nodule <5mm, LDCT in 12 mos. Nodule 5.1 to 10mm in width, follow up LDCT in 6 mos. Nodule >10mm in width, follow up in 3 mos. nd After 2 Screening • <5mm in width, no increase, follow up LDCT in 12 mos. If increase, LDCT in 3-6 mos. or consider surgery 5.1 to 10 mm in width, no increase, follow up LDCT in 12 mos. If increase surgery >10 mm in width, no increase, LDCT in 6 -12 mos. If increase biopsy or consider surgery • • nd 2 Screening • • • Non-solid nodules <5 mm in width, follow up LDCT in 12 mos. At least one non-solid nodule >5mm in width, follow LDCT in 6 mos. One or > dominant nodules with solid or part-solid portion follow LDCT in 3-6 mos. nd After 2 Screening • • • All non-solid nodule, no increase, follow up LDCT in 12 mos. If increase, another LDCT in 3 – 6 mos. or consider surgery At least one nodule is >5mm, no increase, follow up LDCT in 12 mos. If increase, surgery Dominant nodules with solid or part solid portion, decrease, follow up in 12 mos. If same or increase see recommended care for solid or part solid nodule. Infection/Inflammation or Cancer • Follow up LDCT in 1-2 months after treatment for infection/inflammation After Follow Up LDCT for Infection/Inflammation or Cancer • • • • Nodule gone, follow up LDCT in 12 mos. Nodule smaller, follow until nodule gone/stops shrinking, follow up LDCT in 12 mos. Nodule same size or >, > 8mm, PET/CT, if not likely cancer, follow up LDCT in 3 mos. Nodule same size or larger >8mm, maybe cancer, refer for biopsy or surgery Source: National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Lung Cancer Screening, version 2.2014. SAMPLE Letter to High Risk Patients in the Community New Low-Dose CT Lung Screening Program Early detection saves lives. It could save yours. Dear <Patient Name>, I’m proud to share with you that Medical Center is now offering a Low-Dose CT Lung Screening program. The purpose of this program is to save lives by detecting lung cancer early, when it is easier to treat. An annual low-dose CT scan is one of the most effective ways to detect early-stage lung cancer, before symptoms start to occur. As the Lung Nurse Navigator, I work closely with the physicians of Medical Center. Together, we want to make you aware of this new program. Based on a review of your health records, you may be a candidate for the screening. WHO SHOULD GET A LOW-DOSE CT LUNG SCREENING? Candidates for low-dose CT lung screenings should meet the following criteria. Ages 50-74 years old History of heavy smoking Either current smokers or smokers who have quit within the past 15 years Additional risk factors include: Having cancer in the past Having emphysema or pulmonary fibrosis Having a family history of lung cancer Exposure to certain substances, including asbestos, arsenic, beryllium, cadmium, chromium, diesel fumes, nickel, radon, silica and uranium. HOW IS THE SCAN PERFORMED? A low-dose CT lung screening is a scan that produces a 3-D image of the lungs. The scan takes less than 10 seconds. No medications or needles are used. You can eat before and after the exam. HOW MUCH DOES THE SCREENING COST? There could be an out-of-pocket cost of $XXX for this screening; however, it is covered by some insurance companies. Please contact me if you have any questions about cost and insurance coverage. HOW DO I SCHEDULE OR LEARN MORE? Please call me, Jane Doe, Lung Nurse Navigator, at XXX-XXX-XXXX. I can answer your questions, talk through the required criteria and help you schedule a screening. I also welcome you to discuss this with your primary care doctor at your next appointment. Sincerely, Lung Nurse Navigator Medical Center Oncology’s Role In Population Health Questions? Thank You for Your Interest Ira M. Klein, MD, MBA [email protected] Robert Kropp, MD [email protected] Harlan Levine, MD [email protected] Kavita Patel, MD [email protected] Kelley D. Simpson [email protected]