Download OMH(MK)v2

Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Aetna’s Oncology Medical Home
Pilot
Michael Kolodziej, M.D., FACP
National Medical Director, Oncology Solutions
Aetna
Our values guide our approach to creating
a better health care system
Our cause
To make quality health care more
affordable and more accessible
Our strategy
To be the global leader in
empowering people to live
healthier lives
2
Cancer is the most costly medical item,
increasing at 2-3x the rate of other costs
1000%
Cancer care is
the leading
edge of
medical cost
trend
0%
Cumulative
percentage
increase
1996
Aetna's top
cost drivers
in cancer care
$55 B
Annual
Increase
$123 B
Cancer Drugs
20%
Cancer Medical 12-18%
Health Care
9%
US GDP
3%
2010
Medical Rx
Inpatient
Radiology
Specialist Physician
30.8%
23.3%
22.4%
9.4%
$1.5B
$1.1B
$1.1B
$483M
*2010 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC
www.cancer.gov/newscenter/pressreleases/2011/CostCancer2020
3
Privileged and Confidential
The health care system produces
$750 billion in yearly waste
Prevention failures
Unnecessary
services
7%
27%
Fraud
10%
U.S.
health care 14%
system
waste
25%
Excess administrative
costs
~30%
Inflated
prices
17%
of health
spending
is waste
Inefficient
care delivery
Source: Institute of Medicine; 2009 data
4
As community oncologists migrate to
hospital systems, cost increases
•
172 clinics closed
•
323 practices
struggling financially
•
44 practices sending
ALL patients
elsewhere for
treatment
•
224 practices
acquired
by a hospital
•
Source: COA Practice Impact Tracking Database
102 practices
merged/acquired
5
What are the PCMH joint principles?
• Patient has an ongoing relationship with a personal physician
― Personal physician leads a team of individuals that takes
responsibility for the ongoing care of patients
― Personal physician is responsible for providing for all the
patient’s health care needs or arranging care with other
qualified professionals
• Care is coordinated across health care system
• Quality and safety are hallmarks of the medical home
• Enhanced access to care is available through systems such as open
scheduling, expanded hours and new options for communication
• Payment recognizes the added value provided to patients who
have a patient-centered medical home
6
Expected benefits to health care consumers
• Improved health outcomes
• Reduced hospitalizations and ambulatory care
― Includes primary and readmissions
― Includes sensitive specialty/facility and other
costs
• Improved transition of care
• Shared decision-making
• Increased engagement in preventive health and
wellness
7
8
How does this apply to oncology?
•
•
•
•
•
•
Evidence-based medicine
Enhanced access
Shared decision making
Coordination of care
Quality reporting
Payment reform
9
Privileged and Confidential
10
Results on evidence-based medicine
adherence
Pre-Pilot Baseline Adherence
Pilot Group Adherence
For every 100 patients treated in 6
oncology practices in the 6 months
prior to using the clinical decision
support system, 62 received an
evidenced based treatment plan
For every 100 patients treated in 6
oncology practices when using the
clinical decision support system
during the pilot, 87 received an
evidenced based treatment plan
























































Patient receiving an evidence based treatment plan
Patient receiving a non-evidence based treatment plan
•
Our study showed a 43% relative improvement in adherence to evidence based treatment selection.
•
Peer-reviewed, published evidence-based treatment options, sourced from leading oncology guideline
bodies such as the American Society of Clinical Oncology and the National Comprehensive Cancer Network,
were selected for 25 more patients for every 100 cancer patients in our study.
11
Adherence to evidence-based medicine, by cancer type
Results exceeding our expectations
Across the board, our hypothesis was confirmed relative to increased adherence to EBM
Baseline adherence data on more than 200 patients was pulled from chart review of 5 practices for
the 6 month period prior to the start of our pilot.
We compared our study group of 103 patients against this baseline data, examining changes in
evidence-based adherence. In total, the absolute increase was 25%, a 43% relative increase.
Pre-/Post- Study Comparison in Adherence to Evidence Based Medicine
100%
100%
91%
87%
79% 79%
75%
89%
89%
79%
69%
62%
61%
51%
50%
Baseline
Study
0%
25%
0%
Study Sample Size
Total
Colorectal
Breast
Lung
Lymphoma
Other
103
28
22
18
8
27
12
Pathways require…
• Evidentiary and operational process
• Measurement and reporting
13
Privileged and Confidential
Pathways are derived from focus on
high-quality, cost-effective regimens

Eligible for instant
authorization

Eligible for instant
authorization

Eligible for instant
authorization

Eligible for instant
authorization
Eligible for:
 Instant authorization
 Quality Performance Plan
14
15
16
17 17
18 18
Clinical decision support options
19
20
ER use by chemotherapy patients
Milliman Analysis of Medstat 2007, 14 million commercially insured lives, 104,473 cancer patients, Milliman Health Cost Guidelines 2009,
Fitch K, Iwasaki K, Pyenson B. Cancer Patients Receiving Chemotherapy: Opportunities for Better Management. March 30th, 2010, Milliman
21
Inpatient use by chemotherapy patients
Milliman Analysis of Medstat 2007, 14 million commercially insured lives, 104,473 cancer patients, Milliman Health Cost Guidelines 2009,
Fitch K, Iwasaki K, Pyenson B. Cancer Patients Receiving Chemotherapy: Opportunities for Better Management. March 30th, 2010, Milliman
22
ER visits per chemotherapy patient have
dropped by 70 % since 2005
Source: Dr. John Sprandio. Reused with permission. Do not distribute.
23
Hospital admits per chemotherapy patient
have dropped by 50 % since 2007
Source: Dr. John Sprandio. Reused with permission. Do not distribute.
24
How do you accomplish this?
• Triage reform
• Extended office hours
• Patient education
25
Privileged and Confidential
26
Privileged and Confidential
27
28
Deliverables
Patient summary, informed consent and medication sheets
29
Via OncologyTM Pathways’
Treatment Plan
• Auto-generated for both onand off-Pathways decisions
• Contains state/stage of Dx,
treatment details, risks,
monitoring plan, etc.
• Can be edited, printed and
saved within Pathways
• Contents can be securely sent
real time to EMR, practice staff
and payers
• Customizable by practice
30
Via OncologyTM Pathways’
Treatment Plan Summary
• Auto-generated at end of Tx
– State/stage of disease
– Actual treatment delivered
• Can be edited, printed and
saved within Pathways
• Pre-populated with
Survivorship Pathways
(includes Surveillance Plan)
• Ability to display:
– Response, reason for stopping
– Actual toxicities and
hospitalizations
• Customizable by practice
31
Quality reporting: clinical process
measures
• Adherence to evidence-based treatment guidelines
(including treatment exceeding lines of therapy and
documentation of off-Pathways reasons)
• Cancer staging
• Performance status
• Pain assessment
• End-of-life metrics (ACP documentation, hospice
enrollment, hospice length of stay)
• Patient satisfaction
32
Quality reporting: financial measures
These measures form the basis for the shared savings
calculation:
• ER visits (and costs)
• Hospitalization rate (and costs)
• Chemotherapy costs
33
34
Analytics: goals of process
•
•
•
•
Standardize practice benchmarking
Identify opportunities for improvement
Form basis for shared savings
Communicate
35
Our analytics process
1. Identify eligible patients by TIN/state or ZIP code
2. Initial ICD-9 with initial J code
3. “Group” claims using Aetna standard
methodologies (cost categories)
4. Standardized query: opportunity to change single
variable
36
ER and hospital: index practice
ER
IP
IP LOS
Breast (n=52)
29
24
3.7
Colon (n=14)
14
21
8
Lung (n=24)
18
31
5.4
Total
61
76
5.6
37
Chemotherapy costs
N
ME
CP
Breast
52
28325
25307
Colon
14
28819
38616
Lung
24
19576
17892
38
Reimbursement models
•
•
•
•
•
Management fee
Enhanced fee schedule
S codes
Implementation fee
Shared savings
39
S codes
•
•
•
•
Treatment plan
End-of-treatment summary
Advanced care plan
Oral chemotherapy management fee
40
Success requires participation
•
•
•
•
•
Enroll as many patients as possible
Learn from your peers
Work smarter, not more
Trust us as a partner
Remember, we are learning with you
41
Enablement of oncology-specific
component for ACOs
Text
Hospital
Oncology MH solution
+
Text
Oncology
Practice
ACO
Text
Payor
Community Oncology
Practice
Text
Primary Care
Practice
1 Aetna contracts with
community oncology practices
to become medical homes
2 Aetna leverages ACS to
facilitate relationships
between enabled oncology
practices and ACOs
42
43
Aetna OMH network
This could
be you
44
Thank you
45