Download Building a Regional Cancer Care Collaborative

Building a Regional
Cancer Care Collaborative
Presented by:
• Michael L. Blau
Foley & Lardner LLP
[email protected]
617-342-4040
• Cory Jones
Catholic Health Initiatives
[email protected]
720-568-3704
• Tony Melaragno, M.D.
Legacy Good Samaritan Medical
Center
[email protected]
503-413-6875
• William T. Sause, M.D.
Intermountain Health Care, Inc.
[email protected]
801-507-3838
Introduction
Presented by:
Cory Jones
Catholic Health Initiatives
[email protected]
720-568-3704
1
The OHSU-Legacy Cancer
Collaborative
A Regional/Community
Based Program
Presented by:
Tony Melaragno, MD
VP Behavioral Health and Oncology Services
Legacy Health
[email protected]
503-413-6875
2
OHSU-Legacy Cancer Collaboration
• Began July 2013
• Includes all radiation oncology for both organizations
– 5 sites
• Includes all community medical oncology and
infusion in 5 counties
– 6 current sites
• Co-managed by both organizations with an Executive
steering committee with equal representation by
both parties
• Finances fully integrated and net income distributed
based on baseline organizational contributions
3
OHSU-Legacy Cancer Collaboration
What Drives Success of Partnership
• Both Parties Bring Key Ingredients to the
collaboration
– OHSU
• Academic Institution
• The Knight Cancer Institute with expertise and vast
financial resources
• Community network of strong Hematology Oncology
providers
• Access to Personalized Medicine and Advanced
Research protocols
4
OHSU-Legacy Cancer Collaboration
What Drives Success of Partnership
• Both Parties Bring Key Ingredients to the
collaboration
– Legacy Health
• Regional system with multiple hospitals and a large
network of Primary Care clinics
• Strong tradition of surgical oncology, especially breast
specialists and innovation in radiation oncology
• Continuous growth in volume of cancer diagnoses
• Long history of Commission on Cancer Accreditation as
a System (with commendation)
5
OHSU-Legacy Cancer Collaboration
What Are the Challenges
• Collaborators but still Competitors
• Fear of the “University” stealing patients
• Realigning Existing Referral Patterns
• Certain Operational changes by one partner
may need to be vetted with the other
• Educating individual site staffs that it’s okay for
a patient to go to another collaboration site
• Varying Insurance contracts
6
OHSU-Legacy Cancer Collaboration
Advantages
• Patients can receive quality cancer care at site
convenient for them
• Organizations use collaborative process to decide on
New Technology – reducing duplication and cost
• Providers design quality metrics and dashboards
across sites - compared on a regular basis
• Providers and staff can be shared across sites when
needed
• Working toward utilizing proven treatment pathways
across the community platform
7
OHSU-Legacy Cancer Collaboration
Research
• One of the original drivers of collaborative
• Legacy had large number of patients with various cancer
types
• Community providers wanted to participate in research at
their site
• Both organizations had various memberships in
Cooperative groups
• Hurdles to overcome
• Each organization had separate IRBs
• Each organization needed “credit” for enrollment to
maintain accreditation
• Organizational control, Sorting out the finances
8
OHSU-Legacy Cancer Collaboration
Research – Successes
• Developed a Memorandum of Understanding
between 2 organizations defining guidelines
and responsibilities for each
• More effective collaborations between
research coordinators of each org
• Increased accrual for both organizations
• Still sorting out research aspects around
genetic typing of tumor tissue
9
OHSU-Legacy Cancer Collaboration
Current Status
• Continue to see expansion of infusion volume
• Gradual shift in referral pattern from For profit
provider network to collaborative
• Building of trust between providers from the 2
organizations
• Interest from other organizations about potential
inclusion in the collaboration
• How do you include new members
• Financially successful for both organizations
10
Intermountain Healthcare
Case Study
Presented by:
Dr. William Sause
Intermountain Healthcare
[email protected]
801-507-3838
11
12
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IHC Market Share 1999
Cancer Services
• UCR Inpatient share averaged 39% 1995 - 1999
– This is the same as overall average share for all
services
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• IHC Market share for 1999 by type:
Cancer Type
IHC
UofU
Others
Breast
Prostate
Lung
Melanoma
Rectum
22%
36%
22%
48%
27%
58%
45%
49%
34%
54%
20%
19%
29%
18%
19%
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Challenges
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Monopoly creates some degree of
physician alignment
Monopoly delays innovative
strategies to create physician and
institutional alignment
Geographic barriers make sub
specialization a challenge
Impossible to address all care
processes
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19
Quality Improvement
Hierarchy
of Challenges
1. Compliance Study & Operational Goal
2. Adherence to NCCN Guidelines
3.
New Clinical Science Evidence
4. Conflict of Incentive
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Quality Improvement and
Research
Tumor-Specific Projects
Melanoma
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Melanoma Database
Ear Melanoma Study
Urologic Cancers
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Lung Cancer

Pre-Operative Imaging
GYN Cancers
 Endometrial Cancer Study
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Ovarian Cancer Study
Endometrial Familiality Study
PAP & HPV Testing
Endometrial Lynch Syndrome
Stage III Radiation
Myometrium Invasion
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Prostate Quality of Life Study
Radiation Treatment Templates
Renal Cancer Database
Finasteride
Familial Polyp
Prostatectomy Length of Stay (LOS)
Prostatectomy Variable Cost Evaluation
Physician Report Card
PSA Recurrence
Prostatectomy Margin Status
Other
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Multi-clinic Downstream Revenue
Neuro-Oncology Database
Quality Improvement and
Research
Breast Cancer
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ER/PR Specimen Handling
Breast Reconstruction
Oncotype DX Testing
MRI Utilization in Breast Cancer Patients
Short-Term Imaging Follow-Up
Sentinel Lymph Node
Tissue Procurement
Time to Biopsy
Mammography Callback Rate
Early Stage Adjuvant Radiation Therapy
Node Dissection Rate for DCIS
DCIS at Diagnosis
Axillary Dissection Following Positive
Sentinel Node Biopsy
Early Stage at Diagnosis
Neoadjuvant Chemotherapy
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ER/PR Hormone Therapy
 Micro metastasis
• Hypo-fractionation
 Breast Screening Cost
 BIRADS 3
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Colorectal Cancer
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Stage III Chemotherapy
Rectal Cancer – Endoscopic Ultrasound
Colon Familial Polyp (HICCP-UPDB)
Metastatic Colon Cancer Tissue
Colon 12 Node Retrieval
HPNCC Genetics Study
Pancreaticoduodenectomy Study
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STUDY
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Patients are tracked using
mammography tracking software that
has been implemented and standardized
across all facilities
1,454 patients were identified as having
a lumpectomy and radiation between
2003-2007. Of these patients, 1,386
underwent short interval mammography
Patients were identified through
Intermountain Healthcare’s cancer
registry, Intermountain’s electronic
medical record (surgery and radiation
data), and mammography.
29
Conclusion
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Short term mammography may provide a
mammographer baseline anatomic information
Short term mammography following modern breast
conservation has very low yield for new ipsilateral
invasive breast cancer
Eliminating short term mammography would result
in a minimum direct cost savings of approximately
$1,160,000 for this patient cohort over the study
period
This analysis represents a worthwhile
demonstration of comparative effectiveness
research (CER) and has potential to be expanded to
other treatment areas
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2013 Oncology Board Goal
ACTIVE CARE/END OF LIFE CARE TRANSITION
Increase the percentage of newly diagnosed cancer patients
with stage II or higher disease who have documented
evidence (e.g., Advance Directive (AD), Physician Orders for
Life Sustaining Treatment (POLST) Form, or Advance Illness
Discussion (AID) Note) indicating that they have discussed
the seriousness of their illness and possible need for End of
Life (EOL) care.
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Average Charge 2012

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Lumpectomy/Radiation
$16501
Mastectomy/Reconstruction $40057
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Challenges
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35
Cultural Process
Misaligned Incentives between providers/payers
Who benefits from the savings?
Overhead costs for quality improvement
infrastructure
Outpatient measurements are lacking
No guarantee that quality improvement reduces costs
Process Cost improvement may be minimal relative
to optimal utilization(Rationing)
Process savings overshadowed by technological and
pharmaceutical costs?
Does new technology and pharmacy cost make
adaptation of this process imperative?
Cancer Program Development
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Disparate system
Independent budgets
Individual physicians or employed
physicians are RVU rewarded
Representative Patent Litigation Matters by
AttemptJurisdiction
to unite around care processes
and quality
Integration of value based care
nascent.
Substantial challenges with imperfect
implementation
36
Building a Regional Cancer
Care Collaborative:
Structural Options
Presented by:
Michael L. Blau
Foley & Lardner LLP
[email protected]
617-342-4040
37
Select Structural Options for Regional Cancer
Care Collaborative
•
•
•
•
•
•
Affiliation Agreement/Regional Cancer Council
Contractual or Equity JV/Financial Consolidation
Hospital Within A Hospital
RT Joint Venture Technical Service Company
New JV Cancer Facility
Align Oncologists Through Employment/PSA or other
alignment strategies
38
Affiliation Agreement
Regional
Cancer
Council
AMC/Community
Hospital
Affiliation
Agreement
o Representation of stakeholders
o Coordinated planning and services
Hospital
Affiliate(s)
Oncology
Groups
Notes
• Oncology services provided under separate licenses of affiliated hospitals and medical groups,
and billed separately: no economic alignment
• Oncology program may be co-branded with a common name
• Council establishes clinical and operational standards for co-branded oncology program
• No license/CoN process implicated
• Antitrust pricing, market allocation and data exchange constraints
39
Equity JV/Financial Consolidation
Pooled
Oncology P&Ls
AMC/
Community Hospital
Management
Services
Strategic
Affiliation
Agreement
Ownership
Hospital
Affiliate(s)
o Hospitals contribute
oncology staff/certain
equipment
o Financially
consolidate oncology
operations
ManageCo
Notes
• Financial consolidation and equity in ManageCo limited to affiliated Hospitals (not oncologists)
• Oncology services provided under separate licenses and billed under provider numbers of
affiliated Hospitals and oncology groups
• Equity in ManageCo based on relative value of contributions
• Certain centralized management services for oncology service lines
• ManageCo co-manages oncology program (through ManageCo governance process)
• Oncology program may be co-branded with common name
• No license/CoN process implicated (unless major equipment is transferred to ManageCo)
• May require HSR filing if more than $73 million of value contributed
40
Hospital Within A Hospital
AMC/
Community Hospital
Space lease/
support services
Hospital
Affiliate
Hospital Affiliate
provides space, and
possibly equipment
and/or staff
Ownership/License
Hospital within Hospital
Affiliate space
Hospital
Within Hospital
Affiliate
Notes
• License and CoN (in CoN states) required for hospital within hospital
• Tenant hospital has to meet physical separation standards (separate entrance, waiting area, staff,
etc.)
• Oncology services provided under license and billed under provider numbers of tenant hospital
• Tenant pays lessor Hospital fair market value for space and other support services provided by
Hospital Affiliate
• Oncology program may be co-branded
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RT JV Technical Service Company
AMC/
Community Hospital
Hospital
Affiliate(s)
Payors
Oncology
Group(s)
Physician
office rates
$
o License space
o RT equipment
o Leasehold
improvements
o Non-clinical staff
Technical
Management
LLC
Oncology
Group
Technical Service
Agreement
ROs/RTs
Notes
• Model cannot be used for medical oncology services
• New sites or upgrade vs. just existing sites/services
• Stark: LLC cannot “perform” the RT services (e.g., oncology group needs to employ RTs); exclusive
use of space (problematic for inpatient services, which are provided under arrangements?)
• Constraints on non-profit/for-profit JVs; Rev. Proc. 97-13 constraints
• Technical Services Agreement payment must be FMV,
• Regulatory approval for transfer of ownership of Lin Accs?
42
New JV Cancer Facility
Hospital
Affiliate(s)
AMC/
Community Hospital
Ownership
Hospital contribute oncology
staff/certain equipment
Cancer Facility
Separately licensed oncology service
Notes
• Cannot be Medicare provider-based (HOPD) unless on campus of one of the JV hospitals
• New license and CoN (in CoN states) needed
• License as new hospital or free-standing clinic
• Could be physician office model (in certain states) or IDTF/Radiation Therapy Center paid at
physician office rates
• Oncology services provided under license and billed under provider numbers of new freestanding Cancer Facility
• Owners share profit/losses from operations
• Can be co-branded
43
Aligning Oncologists: Hospital Provider-Based
Conversion
Hospital provides:
o
o
o
o
Payors
Affiliated
Hospital
License
Provider-based status
Space/equipment
Nurses/techs (off-campus)
Group provides:
Oncology
Sites/Service Line
$
Oncology Group
MSA/Billing Agreement
Notes
• FMV for assets and Onc Group retains cash and A/R
• PSA on fair market wRVU basis (with performance incentives)
• MSA on a fixed fee or budgeted cost plus fair market mark-up basis
•
Billing services at fair market percentage of collections or fixed fee per claim
44
o Physicians/NPs/PAs
o Non-clinical staff
o Nurses/techs
(on-campus)
o Management
services?
QUESTIONS?
47